Pharma Key Flashcards
1
Q
Calcium Channel Blocker (e.g., Diltiazem, Verapamil, Amlodipine)
A
→ Ankle Swelling, Gingival Hyperplasia. (2 swellings: ankle and gingiva).
2
Q
◙ Beta-blockers (e.g., Atenolol, Bisoprolol)
A
→ Bronchoconstriction (Wheezes, SOB, heavy chest…).
3
Q
◙ Beta-Agonist (e.g., Salbutamol
A
)
→ Tachycardia/
Palpitations/
Muscle twitching and
tremors/ Shaky hands/
Hypokalemia. Remember that higher or frequent salbutamol → hypokalemia
4
Q
◙ ACE inhibitors (e.g., lisinopril, enalapril, ramipril)
A
→ Dry cough (Give ARBs e.g., Losartan instead -important-),
Other: Hyperkalemia.
Other: Precipitate recurrent falls in patients who have postural hypotension.
5
Q
◙ Diuretics
√ Loop diuretics (furosemide)
A
→ Hyponatremia, Hypokalemia, Gout (hyperuricemia).
6
Q
√ Thiazide-like diuretics (bendroflumethiazide)
A
→ Hyponatremia, Hypokalemia,
Gout, Postural hypotension, Hyperglycemia.
7
Q
√ Potassium sparing diuretics (spironolactone)
A
→ Hyponatremia, HypeRkalemia, Gynecomastia (breast enlargement).
8
Q
A
9
Q
◙ Metoclopramide
A
√ Extrapyramidal effects
→ dystonia, akathisia, parkinsonism, bradykinesia, tremors.
√ Neuroleptic malignant syndrome
→ high fever,
sweating, tachycardia,
agitation, confusion,
muscle rigidity, neck
stiffness
10
Q
◙ Haloperidol
A
→ Sexual Dysfunction + Gynecomastia.
So, in a man who has erectile dysfunction, one cause → Haloperidol
11
Q
◙ Metoclopramide
A
√ Extrapyramidal effects
→ dystonia, akathisia, parkinsonism, bradykinesia, tremors.
√ Neuroleptic malignant syndrome
→ high fever,
sweating, tachycardia,
agitation, confusion,
muscle rigidity, neck
stiffness
11
Q
◙ Fluoxetine (SSRI)
A
→ Anorgasmia (delayed ejaculation).
Other: hyponatremia → Falls, gait instability, confusion.
So, in a man who has erection but no or delayed ejaculation → Fluoxetine
12
Q
◙ Citalopram/ Sertraline (SSRI)
A
√ Acute closure angle glaucoma → urgent ophthalmology referral.
√ Erectile dysfunction.
√ Hyponatremia → confusion, unstable gait → falls
So, another side effect of SSRIs in the elderly → ↑ risk of falls.
13
Q
◙ Duloxetine (SNRI)
A
→ ↑ Risk of falls especially in the elderly.
So, both SSRIs (eg, Citalopram, Sertraline) and SNRIs (eg, Duloxetine) can
cause frequent falls especially in the elderly.
14
Q
Falls in snri
Ssri
A
SSRI → Falls (due to hyponatremia).
SNRI -Duloxetine- → Falls (due to postural hypotension
15
Q
Gliflozin eg, Dapagliflozin (SGLT-2 inhibitors) (for type 2 DM)
A
→ ↑ Risk of genital infections (eg, balanoposthitis =
inflammation of the
glans penis and prepuce → erythema, itching) → stop or change medication
16
Q
◙ Clozapine (atypical antipsychotic
A
)
→ Agranulocytosis (neutropenia) + Postural hypotension + ↑ body weight.
17
Q
◙ Methotrexate MTX (Anti-metabolite, used in cancer Rx and in immune disease eg, RA)
A
• Pulmonary toxicity (Cough, dyspnea, fever) → Stop if suspected pneumonitis.
• Bone marrow suppression → Stop MTX if significant ↓ in WBCs/Platelets.
• Liver and GI → Stop MTX if abnormal liver enzymes, stomatitis, diarrhea.
18
Q
Statins
A
◙ Others:
√ Although uncommon, one of the side effects of statins is Rhabdomyolysis.
√ Atorvastatin
→ statin-associated myalgia (muscle pain in arms, shoulders, legs)
19
Q
Augmentin
A
Although uncommon, one of the side effects of co-amoxiclav “Augmentin”
is cholestatic hepatitis “drug-induced hepatotoxicity” especially in the elderly.
20
Q
Clozapine
A
√ One of the feared side effects of clozapine is agranulocytosis (severely low
WBCs especially neutrophils ie, neutropenia).
Agranulocytosis manifests as
(Fever, Chills, Muscle aches, Headache, sore throat).
The next step is to request Full Blood Count (FBC) to look for neutrophils count.
√ Another common S/E of clozapine is → Postural hypotension and weight
gain.
21
Q
√ Citalopram, Fluoxetine (SSRIs)
A
can cause Hyponatremia (SIADH) → confusion,
lethargy.
22
Q
√ Spironolactone (aldosterone antagonist
A
) can cause breast enlargement
(gynecomastia).
23
Q
√ Oxybutynin (anticholinergic
A
) can cause dry eye and dry mouth.
24
√ Antipsychotic medications (eg, risperidone) can elevate
↑ prolactin levels,
and causing galactorrhea (milk discharge from nipples).
25
√ Be aware that glucocorticoids (eg, prednisolone) can cause
leucocytosis and
thrombocytosis (↑WBCs, ↑Platelets).
26
Carbimazole (an antithyroid medication used for hyperthyroidism
) can also
cause agranulocytosis (ie, neutropenia).
27
When replacing one analgesic with another, the dose should
be modified as follows:
◙ From [Oral morphine to Subcutaneous morphine] → (÷ 2)
◙ From [Oral morphine to Subcutaneous diamorphine] → (÷ 3)
◙ From [Oral tramadol to IV morphine] → (÷ 20)
28
A palliative patient is being receiving end-of-life care (at home) by his family.
He has multiple seizures. What is the best route to receive Benzodiazepines?
“at home”, “end-of-life care”
“diazepam” (cheaper, more available)
29
Loop diuretic
Thiazide-like diuretic
Potassium-sparing diuretic
e.g. Furosemide bumatenide
e.g. Bendroflumethiazide indapamide
e.g. Spironolactone eplerenone
Hyponatremia
Hyponatremia
Hyponatremia
Hypokalemia
Hypokalemia
HypeRkalemia
L00p- Gout
TLD- Gout (hyperuricemia) Postural Hypotension
Hyperglycemia
(impaired glucose tolerance)
K sparing-Gynecomastia
30
A diabetic patient with HTN started taking anti-hypertensive medication.
A
few months later, his fasting blood glucose is 15 mmol/l. what is the most
likely drug he has been taking?
Hyperglycemia → bendroflumethiazide (Thiazide-like diuretics)
31
◙ A congestive heart failure patient has started taking Furosemide. What
electrolyte disturbances are expected?
→ Hyponatremia (< 135) + Hypokalemia (< 3.5)
32
A 4 YO child has been brought to the ED unconscious after he has ingested
methadone mistakenly
. Naloxone has been given. However, after a while, he
has become drowsy again. Why?
→ Naloxone has shorter a half-life compared to methadone.
this is why repeated doses of naloxone are sometimes given)
33
There are 4 medications that need to be stopped if a patient presents
with Diarrhea/ Vomiting (Risk of Dehydration) until symptoms resolve:
1) 2) 3) 4) Diuretics ACEE inhibitors Metformin nsaids DAMN
(eg, Furosemide, bendroflumethiazide) → (↑ dehydration).
(eg, enalapril) and (eg, Losartan) arbs → (AKI).
→ (↑ lactic acidosis in a patient with dehydration).
ARBS
NSAIDs → (AKI)
Risk of Dehydration (Hx of Diarrhea/vomiting) → stop DAMN
34
A patient with a Hx of 3 days abdominal pain, fever, diarrhea and vomiting. He
is on multidrug for DM, HTN, long term management of depression.
His
medication history includes metformin, losartan and sertraline.
His urea and
creatinine are found to be mildly elevated. What is the most appropriate
action?
→ Stop Metformin and Losartan (ARBs) Temporarily.
35
Painful Muscle Spasm → Give muscle relaxant eg, ◙
This might be asked in the exam: For example, a long Scenario of a patient
with a history of bone metastasis causing bone pain that is CONTROLLED with
morphine but there is still muscle spasm that is irritating or painf
l.
(a muscle relaxant can be given as an adjuvant).
Rx → Baclofen
36
37
39
◙ Metoclopramide
√ Extrapyramidal effects
→ dystonia, akathisia, parkinsonism, bradykinesia, tremors.
√ Neuroleptic malignant syndrome
→ high fever,
sweating, tachycardia,
agitation, confusion,
muscle rigidity, neck
stiffness
40
41
42
43
44
45
46
Metoclopramide is an antiemetic that blocks dopamine receptors and thus
may cause parkinsonism effect (eg, Neck stiffness and ↑ muscle rigidity).
If the patient is already with a history of Parkinson’s disease (on co-
careldopa), metoclopramide can worsen the muscle stiffness and rigidit
y. Procyclidine
(anticholinergic: It can ↓ the effects of the cholinergic
excess that resulted from dopamine deficiency caused by metoclopramide).
47
◘ Muscle Spasm → Baclofen (1st line)
• Baclofen is a skeletal muscle relaxant that can be used in muscle spasms that
might occur in
multiple sclerosis,
cerebral palsy
, spinal cord injury
or after stroke
or as an adjuvant with radiotherapy in bone metastasis.
Other useful medications to know → Botulinum toxin (= botox), Diazepam
48
49
◘ Drug-induced parkinsonism (eg, tremors, neck stiffness and ↑ muscle
rigidity.
Example of drugs that can cause parkinsonism: metoclopramide,
Procyclidine. (
RX of drug induced Parkinsonism Anticholinergic).
aripiprazole.
Procyclidine is an anticholinergic: It can ↓ the effects of the cholinergic
excess that resulted from dopamine deficiency caused by metoclopramide
50
◘ Neuropathic pain → Amitriptyline (1st preferred) or “Shooting, electric shock like, Burning, Paraesthesia”
→ Amitriptyline (1st preferred) or “Shooting, electric shock like, Burning, Paraesthesia”
or Gabapentin Duloxetine or Pregabalin.
Away Goes D neuropathic Pain
52
◘ Trigeminal neuralgia → Carbamazepine = Anticonvulsants.
◘ Bone pain due to bone metastasis:
Radiotherapy. If fails to control pain:
Bisphosphonate e.g. (Alendronate, Risedronate) First line radiotherapy
→ Second line bisphoshonate
→ If there is some remining muscle spasms, ADD baclofen as an adjuvant.
53
Important Side effects of Calcium Channel Blockers (e.g.
Diltiazem) to be remembered:
Ankle swelling
Gingival hyperplasia
So, for one who take CCB such as diltiazem, amlodipine, verapamil,
nifedipine, he might get swelling of his → Ankle/ Gingiva.
54
◙ An alcoholic wants to quit drinking, what should be given to
reduce his withdrawal symptoms?
√ Note that the question asks about the drug that would alleviate the
“withdrawal symptoms”. In this case, it would be
◙ An alcoholic wants to quit drinking, what should be given to
reduce his withdrawal symptoms?
√ Note that the question asks about the drug that would alleviate the
“withdrawal symptoms”. In this case, it would be
→ Chlordiazepoxide.
55
56
√ If the question asks about a drug that would prevent Craving, the answer
would be →
Acamprosate.
57
√ If the question asks about a drug that would act as a deterrent (abstinence),
the answer would be →
→ Disulfiram
58
√ If he develops hallucination, seizure (delirium tremens) →
Lorazepam
59
Acute alcohol withdrawal: sweating, tremors, altered mentation, ± Hallucination
→ Chlordiazepoxide “First” + Thiamine (Vit. B1)
60
√ If with “seizure”
→ IV Lorazepam. Or Diazepam “If IV Lorazepam is not in the option
61
Wernicke’s encephalopathy (CAS: Confusion, Ataxia, Squint: ophthalmoplegia,
Nystagmus, diplopia), may present
12-24 hours after stopping alcohol as well.
→ IV Vitamin B1 (Thiamine) (IV Pabrinex) or (High potency Vitamin B Complex).
62
√ An alcoholic wants a medication to serve as a Deterrent when he takes alcohol
“Abstinence” →
Disulfiram.
63
An alcoholic wants a medication to reduce his Craving for alcohol →
Acamprosate
64
√ An alcoholic wants a medication to reduce withdrawal symptoms
→ Chlordiazepoxide
65
◙ Opioid (e.g. Heroin) overdose → give
Naloxone.
66
◙ Opioid (e.g. Heroin) wants to quit opiate, the drug that helps him combat
withdrawal symptoms
→ Methadone
67
◙ Opioid (e.g. Heroin) overdose
→ give Naloxone.
68
◙ Opioid (e.g. Heroin) wants to quit opiate, the drug that helps him combat
withdrawal symptoms →
Methadone
Methadone is the Method number 1 for (detoxification); reducing withdrawal
symptoms in opioid addicts.
69
Beta-blockers (e.g. Atenolol) important side effect
→ Bronchoconstriction.
70
Beta-Agonist (e.g. Salbutamol) important side effect
→ Tachycardia.
71
Example, A29 YO patient presents to the ED with tachycardia, palpitations and
chest pain. She is an asthmatic and her GP has recently changed her medication.
(she is asthmatic and salbutamol which is a short-
acting-beta2 agonist is known to cause Tachycardia).
Review medication
72
Remember that CRAP-GPs (The most important ones: Carbamazepine,
Rifampin, Alcohol “chronic”, Phenytoin, Phenobarbital)
if given in a patient
taking Combined Oral Contraceptive pills, they would decrease the efficacy of
COCP. Therefore,
→ advice patient to use alternative method for contraception such as barriers.
73
√ If other drugs such as clarithromycin/ azithromycin/ Amoxicillin are given
with COCP →
No change to contraceptive methods.
○ Also, remember that enzyme INDUCERS → DECREASES (↓) INR
○ While, enzyme INHIBITORS → INCREASES (↑) INR
74
P450 Enzyme Inducers
Decreases Warfarin effect → ↓INR
If used with COCP, an additional
contraceptive method is needed
(e.g. Depo-Provera, IUS, barrier
methods) as these enzyme inducers
weaken the COCP and POP.
• Carbamazepine
• Rifampin
• Alcohol “Chronic”
• Phenytoin
• Griseofulvin
• Phenobarbital
• Sulphonylureas
75
P450 Enzyme Inhibitors
Increases Warfarin effect → ↑ INR
If used with COCP, no need to
change anything.
• Sodium Valproate.
• Isoniazid.
• Cimetidine.
• Ketoconazole.
• Fluconazole.
• Alcohol (Acute drinking).
• Chloramphenicol.
• Erythromycin (Macrolides:
Clarithromycin, Azithromycin)
• Sulfonamides.
• Ciprofloxacin.
ys.com (Constantly updated for online subscribers)
• Omeprazole.
• Metronidazole
76
Remember,
if a pregnant woman is taking sodium valproate,
she needs to
take 5 mg folic acid daily until the 12th week of gestation.
77
78
An elderly ♀ presents with chest infection and thus was started on
clarithromycin.
Her Hx includes, taking Carbamazepine for trigeminal
neuralgia, taking Warfarin for mechanical valve replacement, taking
Bisoprolol, Amlodipine and Atorvastatin.
Her INR was found to be 1.4 (The
target for mechanical valve replacement is 3-4). What is the causative drug for
this low INR?
The answer → Carbamazepine
◙ Carbamazepine is P450 enzyme inducer;
thus, it will decrease the
anticoagulant effect of Warfarin and therefore leads to low INR.
79
An elderly ♀ presents with chest infection and thus was started on
clarithromycin. Her Hx includes, taking Carbamazepine for trigeminal
neuralgia, taking Warfarin for mechanical valve replacement, taking
Bisoprolol, Amlodipine and Atorvastatin.
Her INR was found to be 5.9 (The
target for mechanical valve replacement is 3-4). What is the causative drug for
this HIGH INR?
The answer → Clarithromycin
Clarithromycin is a Macrolide (like erythromycin),
it is P450 enzyme inhibitor
and thus leads to increase the anticoagulant effect of Warfarin and therefore
high INR
80
A lady on COCP has been prescribed doxycycline to manage Lyme disease.
What should be done regarding her contraception?
→ Continue COCP with no additional contraceptive methods.
Doxycycline is not hepatic enzyme inducer; thus, the effectiveness of COCP
will remain the same. Hence, no change is required.
81
A lady on COCP has been prescribed Anti-TB medications.
Non What should be
done regarding her contraception?
→ Consider alternative/ additional or changing contraceptive method to e.g.
barrier, Mirena, Depo-Provera.
√ Remember, Rifampin (which is one of the hepatic enzyme inducers) is one
of the Anti-TB medications that she is going to receive.
√ Hepatic enzyme inducers (e.g. Rifampin, Carbamazepine, Phenytoin…)
weaken the effectiveness of the COCP and POP. Therefore, other
contraceptive method is required!
√ Note that even after finishing the course of hepatic enzyme inducers, a
female would still need to continue using the safe contraceptive method for
additional 4-8 weeks.
82
Anti TB drugs
◙ Remember, the four Anti-TB drugs are the same in pregnancy.
√ (RIPE) → Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
√ These are not-contraindicated during pregnancy.
◙ Remember,
Streptomycin should be avoided during pregnancy (Harmful to fetus)
83
84
A lady on COCP has been prescribed amoxicillin for an acute episode of otitis
media. What should be done regarding her contraception?
→ No additional precaution is needed.
Amoxicillin is not a hepatic enzyme inducer; thus, the effectiveness of COCP
will remain the same. Hence, no change is required.
85
An 18 YO lady wants contraception as she is sexually active.
She does not
want to use barrier methods. His menstrual cycles are regular (28 day) that
last for 4 days. She has epilepsy and uses carbamazepine.
She does not smoke
and has no history of venous thromboembolism. Of the following,
which is the
most appropriate contraceptive to use?
√ As she is < 20 YO → levonorgestrel IUS and IU copper device are UKMEC 2
(UKMEC 2 = the benefits outweigh the risk.
So, if there is an option with
UKMEC 1, it is better to be used. However, if there is no UKMEC 1, we may
use UKMEC 2).
√ She uses carbamazepine “enzyme inducer” which decreases the efficacy of
COCP, POP and implant. Thus, these are not suitable.
√ The remaining option is Depot medroxy progesterone acetate→ injection). It is UKMEC 1 for 18 YO.
86
An 18 YO lady wants contraception as she is sexually active. She does not
want to use barrier methods. His menstrual cycles are Irregular that last for 8
days. She has epilepsy and uses carbamazepine. She does not smoke and has
no history of venous thromboembolism.
She has migraine with aura Of the
following, which is the most appropriate contraceptive to use?
√ She uses carbamazepine “enzyme inducer” which decreases the efficacy of
COCP, POP and implant. Thus, these are not suitable. So, options (A, B and E
are wrong). Additionally, migraine with aura contraindicates the use of COCPs.
√ We are left with Levonorgestrel IUS and IU copper device. Both are UKMEC
2 in females < 20 YO. However, we may still use them if no other option with
UKMEC 1 is suitable. In this case, since she has irregular menstruation with
prolonged menstrual bleedings, levonorgestrel IUS (e.g. Mirena, Levosert,
Jaydess) is better than IU copper device.
√ So the answer is → Levonorgestrel IUS.
87
◙ The anti-emetic (Metoclopramide) can cross blood brain barrier and thus
cause parkinsonian symptoms (eg, muscle rigidity, neck stiffness, tremors).
To manage → anticholinergics
(eg, procyclidine).
Note,
Parkinsonian symptoms → Parkinson disease features → Bradykinesia “slow
movements” + Resting tremors + Rigidity + Postural instability “Ataxia”)
88
A lung cancer patient with shoulder pain has been shifted from oral morphine
to fentanyl patch due to nausea caused by oral morphine
. He was also given
metoclopramide for nausea and vomiting.
A few hours later, his neck has
become weak and stiff. What is the reason for these new symptoms?
→ Side Effect of Metoclopramide treatment.
89
◙ Important Side Effects of Metoclopramide:
√ Extrapyramidal effects →
dystonia,
akathisia,
parkinsonism,
bradykinesia,
tremors.
√ Neuroleptic malignant syndrome → high fever, sweating,
tachycardia,
agitation, confusion,
muscle rigidity, neck stiffness
90
Steps of Management of Asthma
◘ Step (1): Inhaled SABA (Short-acting beta-2 agonist e.g. inhaled salbutamol)
If asthma is not controlled (a patient uses inhaled salbutamol > 3 doses/ week) → Step 2
◘ Step (2): Inhaled SABA + Inhaled Corticosteroids (e.g. inhaled beclomethasone)
◘ Step (3): Inhaled SABA + Inhaled Corticosteroids + LTRA (leukotriene receptor
antagonist).
◘ Step (4): SABA + Inhaled Corticosteroids + LABA ± LTRA
LABA = Long-acting beta agonists e.g. Salmeterol.
91
Asthma management in short (Nice Guidelines)
1) SABA
2) SABA + Inhaled Corticosteroids
3) SABA + Inhaled Corticosteroids + LTRA (Montelukast)
4) SABA + Inhaled Corticosteroids + LABA (e.g., Salmeterol) ± LTRA
The rest of the steps are not as important; however, study them in case:
5) SABA + Maintenance and reliever therapy (MART) “low-dose inhaled
corticosteroids (ICS)” ± LTRA
6) SABA + Maintenance and reliever therapy (MART) “moderate-dose
inhaled corticosteroids (ICS)” ± LTRA
7) SABA ± LTRA (+) One of the following:
• Further increase the dose of inhaled corticosteroids (or)
• Trial of a new drug (e.g. theophylline) (or)
• Seek professional advice
92
Asthma management in short (BTS Guidelines
1) SABA
2) SABA + Inhaled Corticosteroids
3) SABA + Inhaled Corticosteroids + LABA (e.g., Salmeterol) ± LTRA
4) SABA + Inhaled Corticosteroids + LTRA (Montelukast)
So, be careful, the third step in NICE guidelines is LTRA “e.g., Montelukast”
while the third step in (BTS guidelines is LABA “e.g., Salmeterol”.
The question may include the guidelines. “recently asked 2021 √”
Notes:
• SABA → inhaled salbutamol
• Inhaled corticosteroid → Inhaled beclomethasone
• LTRA → Leukotriene receptor antagonist
• LABA → Inhaled Salmeterol
93
Dry [Non-Productive] Cough √ ACE inhibitors can be a side effect of:
(eg, Ramipril, Lisinopril, Enalapril, Captopril).
And
√ Methotrexate
◙ Why Dry Cough with Methotrexate?
○ Prolonged intake of methotrexate (such as in patients with Rheumatoid
Arthritis) can rarely lead to a severe condition → Pulmonary Fibrosis.
○ Pulmonary Fibrosis → Dry cough, breathlessness, wheezes.
Diffuse bilateral interstitial infiltrates on Chest X-ray may also be seen
94
Antifolate
So, methotrexate is anti-folic acid (teratogenic)
+ it can cause dry cough.
Do you remember another anti-folate medication?
→ Trimethoprim (so, it is contraindicated in the first trimester of pregnancy).
95
Post-operative intractable Nausea and Vomiting:
Give → IV Ondansetron
96
Anti-emetic in vomiting due to Chemotherapy, Radiotherapy, Post-op
→ Ondansetron.
97
◙ Anti-emetic due to ↑ ICP (eg, intracerebral tumour) or vomiting due to
bowel obstruction
→ Cyclizine
98
Anti-emetic in renal failure/ Hypercalcemia (metabolic cause) or Drug or
Toxin induced vomiting
→ Haloperidol. (1st line)
99
◙ However, if there is associated Parkinson’s disease, Haloperidol is
contraindicated! Instead of Haloperidol, we use instead:
→ Cyclizine, or: domperidone or ondansetron (buy not in elderly).
If vomiting persists in Parkinson’s disease → Levomepromazine. (2nd line)
(Never use Haloperidol with Parkinson’s)!
100
Anti-emetics in Hyperemesis gravidarum
√ 1st line: “zine” family eg, Cyclizine, Promethazine
√ 2nd line: IV Metoclopramide, Ondansetron
√ 3rd line: Steroids
101
◙ Vertigo (eg, Meniere’s/ BPPV/ Vestibular neuritis)
→ Buccal Prochlorperazine.
102
◙ Anti-emetic for post-operative intractable Nausea and Vomiting
→ IV Ondansetron
103
◙ Vertigo (eg, Meniere’s/ BPPV/ Vestibular neuritis)
→ Buccal Prochlorperazine.
104
◙ In any patient on warfarin urgently report is
HEADACHE
(This is because people on warfarin are liable to subdural hematoma which
presents with headache and other features)
105
In any patient on bisphosphonates
needs to be urgently reported is
Bisphosphonates, the most important symptom that he
→ Severe, sudden Heartburn ▐ or Chest pain (either is correct)
106
Remember that ACE inhibitors (e.g. ramipril, enalapril) and
Potassium sparing diuretics (e.g. Spironolactone) can cause
→ hypeRkalemia
107
Remember that Loop Diuretics (e.g. Furosemide)
and Thiazide
like diuretics (e.g. Bendroflumethiazide) can cause
and → hypOkalemia Gout
108
When using macrolides (eg, Clarithromycin, Erythromycin)
→ STOP Statins (eg, Atorvastatin, Simvastatin)!
Concomitant use of macrolides + statins is Contraindicated!
109
110
Ulipristal acetate (EllaOne
)
→ inhibits or delays Ovulation
111
Oral Progesterone-only emergency contraceptive Pills – Levonorgestrel
→ inhibits Ovulation
112
Copper IUD as an Emergency Contraception “after unprotected sex
.
→ inhibits Implantation
(inhibits fertilisation).
→ inhibits Implantation
113
◙ N-Acetylcysteine (for paracetamol overdose)
→ Protection from free radicals.
114
◙ Low Molecular Weight Heparin (LMWH)
→ Inhibits the conversion of prothrombin to thrombin (activate the
antithrombin) “
the same initial mechanism for unfractionated heparin as
well”.
115
Tranexamic Acid (for menorrhagia)
→ Inhibits fibrinolysis
116
Calculation of Units of Alcohol
Strength ABV (in %) X Volume (in ml) ÷ 1000 = … Units
○ Beer:
√ 1 pint of beer (3.5%) = 2 Units.
√ 1 pint of premium beer (5-6%) = 3 Units.
○ Wine:
√ Small glass 125 ml = 1.5 unit
√ Medium glass 175 ml = 2 units
√ Large glass 250 ml = 3 unit
○ Cider: 1 pint of cider = 3 units
117
A man drinks half a litre of vodka (ABV 40%) and a pint of beer (3.5%) a week.
40% X 500 ml ÷ 1000 = 20 Units
+
1 pint of 3.5% beer = 2 Units
So, he drinks 22 units a week.
118
UK guidelines recommend that a person should drink
- No more than 14 units a week,
- No more than 3 units a day,
- with at least 2 alcohol-free days a week.
119
◙ Metoclopramide
√ Extrapyramidal effects →
dystonia, akathisia,
parkinsonism, bradykinesia,
tremors.
Neuroleptic malignant syndrome → high fever, sweating, tachycardia,
agitation, confusion, muscle rigidity, neck stiffness.
120
121
◙ Haloperidol
l → Sexual Dysfunction + Gynecomastia.
122
Fluoxetine (SSRI)
→ Anorgasmia (delayed ejaculation). Other: hyponatremia
So, in a man who has erection but no or delayed ejaculation → Fluoxetine
123
◙ Citalopram →
Acute closure angle glaucoma
→ urgent ophthalmology referral.
124
Neuroleptic Malignant Syndrome
♠ Neuroleptic malignant syndrome is a rare but dangerous condition seen in
patients taking antipsychotic medication.
♠ Some causing drugs:
√ Haloperidol (Typical Antipsychotic).
√ Metoclopramide (Antiemetic, dopamine antagonist, cross blood-brain-barrier).
♠ Features
√ Onset usually in first weeks of treatment or after increasing dose
√ Pyrexia (fever)
√ Agitation
√ Confusion/ altered consciousness
√ Muscle rigidity (e.g. neck stiffness)
√ Tachycardia
√ Sweating
A raised creatine kinase is present in most cases.
Acute kidney injury
(secondary to rhabdomyolysis) may develop in severe cases.
A leucocytosis
may also be seen
125
Neuroleptic Malignant Syndrome
♠ Neuroleptic malignant syndrome is a rare but dangerous condition seen in
patients taking antipsychotic medication.
♠ Some causing drugs:
√ Haloperidol (Typical Antipsychotic).
√ Metoclopramide (Antiemetic, dopamine antagonist, cross blood-brain-barrier).
♠ Management
• Stop antipsychotic
• Rapid cooling
• IV fluids to prevent renal failure
• Dantrolene “post-synaptic muscle relaxant used in NMS”
• Dopaminergic agent such as bromocriptine
NOTES
♦ Do not use Metoclopramide in nauseous patients with Parkinson’s.
♦ Do not use Haloperidol in psychotic patients with Parkinson’s (use lamotrigine).
So, in Parkinson’s, do not give haloperidol nor metoclopramide
126
10-month-old child who weighs 10 kg has been prescribed trimethoprim for
UTI at a dose of 4 mg/kg twice a day.
The preparation of trimethoprim is
50mg/5ml. What is the dose to be given to this child?
So, the answer → 4 ml BD
127
18-month-old child who weighs 15 kg has been prescribed trimethoprim for
UTI at a dose of 6 mg/kg twice a day.
The preparation of trimethoprim is
40mg/4ml. What is the dose to be given to this child?
So, the answer → 9 ml BD
128
Polypharmacy
√ An old patient (usually > 60 YO)
√ Takes ≥ 5 Medications
√ Presents with dizziness, confusion, Frequent Falls (± Hx of feeling dizzy
a few moments before a fall).
√ Due to postural hypotension (caused by multiple drug intake especially
anti-hypertensives and anti-cholinergics
129
A patient on ramipril and bendroflumethiazide was found to have
serum
potassium of 5.9 (high) and serum sodium of 128 (low)
.
In this case,
○ The Thiazide like diuretics (bendroflumethiazide) has caused
→ hyponatremia.
○ The ACE inhibitor (ramipril) has caused
→ Hyperkalemia.
130
Lithium
√ For Bipolar Disorder.
◙ Before commencing it, do the following tests: “important”
• Renal Function Tests.
• Liver Function Tests.
• Thyroid Function Tests.
• Baseline ECG.
• Others:
Pulse, BP,
Pregnancy Test,
Parathyroid hormone,
FBC, U&E, Ca, Mg
131
◙ If lithium toxicity developed (eg, blurry vision, tinnitus = ringing ears,
dizziness, lethargy,
muscle weakness, diarrhea, vomiting)
→ Stop lithium and repeat serum lithium level every 6-12 hours + Supportive
care (There is no antidote to lithium toxicity).
When toxicity resolves, lithium can be restarted at a lower dose (Never stop
lithium suddenly;
it has to be over a period of 3 months to prevent relapse).
132
When can we use fentanyl patches for pain control in cancer patients?
If the oral route is not tolerated + the pain is STABLE at the shifting time
A patient with nasopharyngeal cancer is being pain controlled on oral
morphine that manages his pain well.
However, he now has difficulty in
swallowing his morphine tablets. What should be done?
→ Replace oral morphine with transdermal fentanyl patch.
(In this scenario, the pain is already stable “controlled”.
Thus, shifting to a
fentanyl patch is appropriate).
If fentanyl patch was not among the options, pick Subcutaneous morphine.
133
When not to use Fentanyl patch even in stable pain?
Example
A terminal bladder cancer patient has lower abdominal pain that is well
controlled with Oral Codeine Phosphate.
However, he is nauseous, and finds
it difficult to keep taking oral medications as he is weak to swallow. What
should be done?
◙ Oral codeine can be replaced by either
√ Buprenorphine patch (best option if given), or
√ Subcutaneous Morphine
◙ Note that he cannot tolerate orally, thus any oral option is WRONG!
◙ Also, Fentanyl patch is inappropriate as it is very potent compared to his
current method of pain control (codeine).
It will be an unnecessary exposure
to more opioids (Overdose).
◙ Finally, there is no Subcutaneous form of Codeine!
134
So, in controlled pain (stable pain)
◘ Change from oral morphine to → Fentanyl patch.
◘ Change from oral codeine to → Buprenorphine patch OR SC morphine.
135
If the pain is not controlled, never shift to Fentanyl Patch!
This is because fentanyl patch needs 12-24 hours to achieve its therapeutic
level (long half-life).
During this period, the patient will remain in pain! We
need something faster!
Example
After an anterior resection of rectum, the pain was controlled with oral
oxycodone. Now, the pain is not controlled and the patient has started to
vomit and cannot tolerate orally.
√ Fentanyl patch is not suitable as the pain is not well controlled.
√ Any oral analgesic is not suitable as he cannot tolerate orally.
→ Shift to IV morphine
136
An elderly with Parkinson’s disease has developed an episode of acute
psychosis and become aggressive.
He punches everyone approaching him in
the face.
The most appropriate immediate Rx → Lorazepam (for rapid tranquilization
)
• Lorazepam is a rapid acting benzodiazepine. (Could be given IM here).
• Haloperidol (Typical Anti-psychotic) is contraindicated in Parkinson’s disease
patients.
• Olanzapine and Risperidone (Atypical Antipsychotics) can exacerbate
Parkinson’s disease.
Note, if the aggressive/ distressed patient has no Dementia, Alzheimer’s, or
Parkinson’s →
we could consider or Olanzapine as a short-term
therapy if non-pharmacological (de-escalation) techniques have failed.
137
◘ Plasma concentration of a drug peaks much faster for IV route
than oral route. Why?
→ Hepatic First Pass Elimination
IV drug goes directly to the systemic circulation “blood” i.e. it does not go to
liver for metabolism which takes time and reduces the drug bioavailability.
√ On the other hand, oral drug goes to gut, then via the portal system to the
liver where it is metabolised and its bioavailability is reduced (takes time).
138
139
140
Features suggesting DVT “Deep Vein Thrombosis (e.g. pain/ swelling of calf
muscles)
Start → Low molecular weight heparin LMWH (enoxaparin) until DVT is ruled out!
141
In Diabetic Neuropathy:
Neuropathic pain can present in any form of the following:
(Burning), (Tingling), (
Numbness), (Itching), (
Paraesthesia), (Shooting/
Stabbing)
Example, a diabetic patient with ankle ulcer with agonising Burning Pain.
Rx? → Amitriptyline (1st line) or Gabapentin or Duloxetine or Pregabalin.
Away Goes D neuropathic Pain
(+) Good glycemic control.
142
A 46 YO man has undergone a surgery to remove mandibular cancer presents
with perioral paraesthesia
and severe perioral pain that is not relieved by oral
morphine and oral ibuprofen. The skin is very tender to touch.
Rx → Amitriptyline (1st line) or
Gabapentin or Duloxetine or Pregabalin
This is likely a neuropathic pain due to nerve injury during the operation.
143
An elderly with terminal prostate cancer with his pain is being controlled with
fentanyl patch
. A few weeks ago, he develops shooting pain radiating down
both his arms to his hands. He describes it as a stabbing pain.
Rx → Amitriptyline (1st line) or Gabapentin or Duloxetine or Pregabalin
144
Doxycycline and many other medications can cause nausea and vomiting if
they were taken orally on an empty stomach. Thus, a simple advice to the
patient
→ to take the medication with meals (not before meals) might prevent nausea.
145
42 YO man weighs 80 kg presents for a procedure.
He was given 20 ml of 1%
lidocaine without epinephrine prior to the procedure.
If the maximum
allowed dose is 4 mg/kg, how much of 1% lidocaine can be given to him?
1% → 10mg/ml (constant)
Max dose: 4mg/kg. He is 80 kg.
So, 4 X 80= 320 mg (max dose)
10 mg ----------→ 1 ml
320 mg ---------→ (X) ml
(X) = (320 X 1) ÷ 10 = 32 ml
He was already given 20.
So, the remaining dose = 32 – 20 = 12 ml
146
Example, A29 YO patient presents to the ED with tachycardia, palpitation and
chest pain.
She is an asthmatic and her GP has recently changed her medicatio
n.
→ Review her medication (she is asthmatic and beta-agonists are known to
cause Tachycardia).
147
Beta blocker and agonist
Beta-Agonists (e.g. Salbutamol, Salmeterol) which are used for Asthma
management can cause Tachycardia and Palpitation,
◙ whereas Beta-blockers (e.g. Atenolol, Propranolol) which are used for
rate-control can worsen Asthma by causing bronchi constriction
148
A 50 YO post-op patient has his pain controlled with oral morphine 60
mg BD.
However, he is now unable to tolerate oral medication, what
should be done?
Shift to continuous Subcutaneous morphine infusion.
What will be the dose??
Let’s analyse it:
√ The patient is pain-controlled on 60 mg BD oral morphine (twice a day),
this means 120 mg in 24 hours.
When shifting from Oral morphine to SC morphine → (÷ 2).
So, he would need (120 ÷ 2) = 60 mg SC morphine in 24 hours
Therefore, the final Answer:
Commence morphine 60 mg per 24 hours by continuous Subcutaneous
infusion.
149
Remember:
When replacing one analgesic with another, the dose should be
modified as follows
Remember:
When replacing one analgesic with another, the dose should be
modified as follows:
◙ From [Oral morphine to Subcutaneous morphine] → (÷ 2)
◙ From [Oral morphine to Subcutaneous diamorphine] → (÷ 3)
◙ From [Oral tramadol to IV morphine] → (÷ 20)
150
A prostate cancer patient was pain-controlled on 600 mg oral
tramadol hydrochloride a day.
He now cannot tolerate oral
medications and therefore, the doctors have decided to shift him to IV
morphine to be given in hospital. What should be the dose of IV
morphine?
From [Oral tramadol to IV morphine] → (÷ 20)
So, 600 ÷ 20 = 30
The answer is → 30 mg.
When shifting from Oral Tramadol to IV morphine → (÷ 20).
151
Selective serotonin reuptake inhibitors (SSRIs).
√ Gastrointestinal symptoms are the most common side-effect.
√ There is an increased risk of gastrointestinal bleeding in patients taking
SSRIs.
√ A proton pump inhibitor should be prescribed if a patient is also taking a NSAID.
◙ Avoid concomitant use of SSRI with: NSAIDs/ Aspirin/ Warfarin/ Triptans.
152
Selective serotonin reuptake inhibitors (SSRIs).
◙ Selective serotonin reuptake inhibitors (SSRIs) are considered first-line
treatment for the majority of patients with depression.
◙ Citalopram and fluoxetine are currently the preferred SSRIs.
◙ Sertraline is useful post myocardial infarction as there is more evidence for
its safe use in this situation than other antidepressants.
◙ SSRIs should be used with caution in children and adolescents. Fluoxetine is
the drug of choice when an antidepressant is indicated.
153
SSRIs can take 2-4 weeks before antidepressant effect can be seen
√ if no response after 2-4 weeks → Check patient’s adherence (compliance).
√ if no response after 4 weeks + the patient is compliant
→ either ↑ dose or switch antidepressant.
A 33 YO man has depression and has been recently started on sertraline (a
SSRI). When can a therapeutic effect be seen?
1-2 hours ▐ 1-2 day ▐ 1-2weeks▐ 1-2 months
The closer answer to 2-4 weeks.
154
Haloperidol
Fluoxetine
◙ Some Side effects:
√ Haloperidol → Sexual Dysfunction + Gynecomastia.
√ Fluoxetine (SSRI) → Anorgasmia (delayed ejaculation).
Other: SIADH “hyponatremia”
So, in a man who has erection but no or delayed ejaculation
The causative drug is → Fluoxetine
155
Antidepressant
Following the initiation of antidepressant therapy patients should normally be
reviewed by a doctor after 2 weeks.
For patients under the age of 30 years or at
increased risk of suicide they should be reviewed after 1 week.
If a patient makes a
good response to antidepressant therapy, they should continue on treatment for at
least 6 months after remission as this reduces the risk of relapse.
√ When stopping a SSRI, the dose should be gradually reduced over a 4-week period
(this is not necessary with fluoxetine). Paroxetine has a higher incidence of
discontinuation symptoms.
√ Discontinuation symptom
156
√ Discontinuation symptoms:
increased mood change, restlessness, difficulty sleeping, unsteadiness, sweating,
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting, paraesthesia
157
Red circular itchy rash → Likely fungal infection
“ringworm infection = dermatophytosis
”
Give → Clotrimazole cream
(Note, Fusidic acid “Fucidin cream” is antibacterial and thus not suitable for fungi)
158
30 YO asthmatic patient on 3 inhaled medications for her asthma. 2 of
which are regular and one is when needed.
She now complains of twitching
and tremors of her hand hands. What is the Culprit medication?
√ The 2 regular inhalers are → LABA (Salmeterol) and Inhaled
Beclomethasone.
√ The 1 as needed inhaler is → SABA (Salbutamol).
The most likely one that has caused tremors is → Salbutamol inhaler
Remember that salbutamol (short acting beta agonist) and salmeterol (long
acting beta agonist) have the same side effects
but salbutamol being used as
needed means that it can be overused and thus is more likely to cause side
effects.
Remember, side effects of:
◙ Beta-Agonist (e.g. Salbutamol)
→ Tachycardia/ Palpitations/ Muscle twitching and tremors.
159
Rx of ascites secondary to Cirrhosis (alcohol abuse, ascites, spider naevi)
→ Spironolactone (Potassium-sparing diuretics). √
160
Pop
Cuiud
◙ Copper IUD as an Emergency Contraception “after unprotected sex”
(inhibits fertilisation).
→ inhibits Implantation
◙ Oral Progesterone-only emergency contraceptive Pills – Levonorgestrel
→ inhibits Ovulation
161
Overdose of coccaine
LSD
Heroin
Notes on Overdose (Intoxication)
◙ Heroin → everything is decreased: low HR, Low RR, Low BP, Pinpoint
(Constricted) pupils.
◙ Cocaine → The Opposite: high HR, high RR, high BP, Mydriasis (Dilated
pupils).
◙ LSD → delusions, hallucinations, a patient sees sounds and smells
colours.
162
Notes on withdrawal:
◙ Heroin → ↑ body secretions (watery eyes, runny nose, diarrhea,
sweating) + Pain (abdomen, muscles) + Others.
◙ Cocaine → DEPRESSION + Others.
◙ Benzodiazepines → Panic attacks + Others.
◙ Alcohol →Nausea, Vomiting, Irritability + tremors ± Hallucinations +
Others
163
Heroin overdose
Respiratory Depression (Low RR)
- Low BP
- Low HR
- Pinpoint pupils (constricted pupil
- Constipation
• Give Naloxone
164
Cocaine
- High RR
- High BP
- High HR
- Mydriasis (dilated pupils)
- Hyperthermia and sweating
- Restlessness and Agitation
165
Ecstasy
• neurological: agitation, anxiety, confusion, ataxia
• cardiovascular: tachycardia, hypertension
• hyponatraemia
• hyperthermia
• rhabdomyolysis
• uncontrolled body movements, Trismus.
Management
• supportive
• dantrolene may be used for hyperthermia if simple
measures fail
166
LSD
(Lysergic Acid
Diethylamide)
Mydriasis – Flushing and sweating – Hyperreflexia-Diarrhea –
Paraesthesia
Delusions and Hallucinations (Pathognomonic)
- a patient smelling colours and seeing sounds → LSD
167
Drug Withdrawal Features
Heroin
Your (heroin) leaves you “Withdrawal”:
• You cry a lot → Watery eyes and runny nose.
• You cannot sleep → Insomnia.
• You miss her → Agitation.
- Withdrawal begins 12 hours after last dose
- Peaks at 24-48 hours
- Increased body secretions: sweating, diarrhea, runny nose,
tearing (Flue-like symptoms esp. early in withdrawal) +
- Pain: Abdominal pain, joints (arthralgia), muscle aches. +
- Others: agitation, insomnia, anxiety (common in other drugs)
168
Benzo-
diazepines
Withdrawal begins 1-4 days and peaks at 2 weeks.
- Panic attacks + Other common (agitation, insomnia, anxiety)
Remember: benzodiazepines are used to treat panic attacks and
anxiety.
169
Cocaine
Within hours of last dose and peaks in a few days.
- Depression, irritability, muscle aches + Others (insomnia …
170
Alcohol
symptoms start at 6-12 hours: tremor, sweating, tachycardia,
anxiety.
• peak incidence of seizures at 36 hours
• peak incidence of delirium tremens is at 48-72 hours:
coarse tremor, confusion, delusions, auditory and visual
hallucinations, fever, tachycardia
171
Alcohol withdrawal mng
Management
• first line: benzodiazepines e.g. chlordiazepoxide.
Lorazepam may be preferable in patients with hepatic failure.
Typically given as part of a reducing dose protocol
• carbamazepine is also effective in treatment of alcohol
withdrawal
• phenytoin is said not to be as effective in the treatment of
alcohol withdrawal seizures
172
Community Acquired Pneumonia
(Moderate)
Amoxicillin + Clarithromycin
Community Acquired Pneumonia
Amoxicillin
173
Community Acquired Pneumonia
Co-amoxiclav + Clarithromycin
Co-amoxiclav = Amoxicillin + clavulanic acid
e.g., Augmentin®
174
Pneumocystis Jirovecii “P. Carinii
” Co-Trimoxazole
= (Trimethoprim + Sulfamethoxazole)
= Bactrim®
175
Tuberculosis (TB)
√ First 2 months → (Ripe) →
Rifampicin, Isoniazid, Pyrazinamide,
Ethambutol.
√ The next 4 months (Ri) →
Rifampicin, Isoniazid.
176
Aspiration Pneumonia
Amoxicillin + Metronidazole
177
CNS (Meningitis)
Out-of-hospital Meningitis Benzylpenicillin
In-hospital meningitis (most types) Ceftriaxone
Listeria Meningitis
Ceftriaxone + Ampicillin + Gentamicin
Cryptococcal Meningitis
Amphotericin B
Meningitis Prophylaxis “for
√ Ciprofloxacin “preferred” or:
contacts”
√ Rifampicin
178
Genitourinary Conditions
Lower uncomplicated UTI
(in a non-pregnant ♀)
Trimethoprim or Nitrofurantoin
Candida albicans (Vulvovaginal candidiasis)
Clotrimazole or Fluconazole
Trichomonas Vaginalis
Metronidazole
179
Genitourinary Conditions
Bacterial Vaginosis (Gardnerella
Vaginalis)
• Trichomonas Vaginalis
Metronidazole
Cervicitis (Chlamydia) Recent Guidelines for the management of
Cervicitis (September 2019)
Chlamydia
◙ 1st line → Doxycycline 100 mg BID for 7
Days.
◙ Another line:
Azithromycin 1-gram PO
Followed by 500 mg PO OD for 2 days.
180
Genitourinary Conditions
1. Cervicitis (N. Gonorrhea) Neisseria gonorrhoea
◙ Ceftriaxone 1 gm IM (single dose). Or:
◙ Ciprofloxacin 500 mg PO (Single dose).
2. PID “Pelvic Inflammatory Disease” Differs based on hospital guidelines,
one example: (CDM)
Ceftriaxone + Doxycycline +
Metronidazole
3. Syphilis Penicillin G
4. Genital Herpes “HSV” Aciclovir
181
GIT Conditions
GIT Conditions
Salmonella/ Shigella/
Erythromycin or Azithromycin or
Campylobacter
Clarithromycin
Or Ciprofloxacin
Clostridium Difficile
“Pseudomembranous colitis”
√ Oral Metronidazole “first line”
√ Vancomycin “if severe”
H. Pylori OAC Regimen (triple therapy)
√ Omeprazole (PPI)
√ Amoxicillin
√ Clarithromycin
182
ENT Conditions
Acute “bacterial” Otitis Media Amoxicillin
URTI “Pharyngitis/ Tonsillitis/laryngitis
Phenoxymethylpenicillin
183
Cellulitis
Mastitis
Diabetic Foot Infection
Flucloxacillin
184
Septic arthritis
Osteomyelitis
Flucloxacillin + Sodium Fusidate
185
Scabies
5% Permethrin
186
Toxoplasmosis
Pyrimethamine + Sulfadiazine
187
Lithium and NSAIDs e.g., ibuprofen Interaction:
→ ↑ renal reabsorption of lithium i.e.,
↓ renal clearance of lithium √.
→ ↑ Risk of lithium Toxicity.
Note, Diuretics and NSAIDs (e.g. Ibuprofen) and Aspirin increase renal
reabsorption of lithium and hence, the serum lithium increases and may lead
to toxicity.
188
189
Liver cancer + Hiccups.
Give → Metoclopramide
190
Lithium therapeutic range
Check lithium levels 12 hours after taking the last lithium dose (as it has a
narrow therapeutic range
191
A patient with DM and HF has been recently prescribed a new medication.
He now presents with polyphonic wheeze and bronchoconstriction. What is
the likely cause?
→ Beta blockers (e.g., Bisoprolol/ Atenolol).
◙ Beta-blockers (e.g. Atenolol, Bisoprolol) important side effect →
Bronchoconstriction.
◙ Beta-Agonist (e.g. Salbutamol) important side effect → Tachycardia.
192
Diabetic patient with heart failure on beta-blockers, ACE inhibitors, insulin
and furosemide was found to have hypokalemia. What is the likely cause?
→ Furosemide.
(Loop diuretics such as furosemide are used in the treatment of heart failure,
and can cause hypokalemia).
193
HypOkalemia
Loop Diuretics (e.g. Furosemide)
• Thiazide-like diuretics
e.g. bendroflumethiazide, indapamide)
• Vomiting and Diarrhea
• Conn’s disease (1ry
hyperaldosteronism)
Renal tubular failure
• Cushing Syndrome
• Villous Adenoma
194
HypeRkalemia
ACE inhibitors.
Potassium-sparing diuretics
e.g. Spironolactone/ Eplerenone)
• Congenital Adrenal Hyperplasia.
Addison’s (1ry Adrenal insufficiency)
CKD
195
A patient with hypertension on treatment presents complaining of ankle
swelling. The likely cause of this ankle oedema is:
(a Calcium channel Blocker)
Amlodipine
196
2 Important Side effects of Calcium Channel Blockers (e.g.
Diltiazem) to be remembered:
◙ Ankle Swelling
◙ Gingival Hyperplasia
So, for one who take CCB such as diltiazem, amlodipine, verapamil,
nifedipine, he might get swelling of his → Ankle/ Gingiva.
197
before commencing Lithium, order:
◙ before commencing Lithium, order:
Thyroid Function Tests. And:
Kidney Function Tests.
◙ Before prescribing Amiodarone
Serum and Electrolytes
Urea measurements should be obtained.
198
An asthmatic patient on 2 inhalers presents complaining of tremors, muscle
twitching and shaky hands after using one inhaler. What is the likely cause?
→ Salbutamol (SABA).
199
Important Side Effects
200
Important Side Effects
◙ Calcium Channel Blocker (e.g. Diltiazem, Verapamil, Amlodipine)
→ Ankle Swelling, Gingival Hyperplasia.
◙ Beta-blockers (e.g. Atenolol)
→ Bronchoconstriction (Wheezes, SOB, heavy chest…).
◙ Beta-Agonist (e.g. Salbutamol)
→ Tachycardia/ Palpitations/ Muscle twitching and tremors/ Shaky hands
◙ ACE inhibitors (eg, lisinopril, enalapril)
→ Dry cough (Give ARBs eg, Losartan instead -important-), Hyperkalemia.
201
Important Side Effects
◙ Diuretics
√ Loop (furosemide) → Hyponatremia, Hypokalemia, Gout (hyperuricemia).
√ Thiazide (bendroflumethiazide) → Hyponatremia, Hypokalemia, Gout,
Postural
hypotension, Hyperglycemia
√ Potassium sparing (spironolactone) → Hyponatremia, HypeRkalemia,
Gynecomastia.
◙ Metoclopramide
√ Extrapyramidal effects → dystonia, akathisia, parkinsonism, bradykinesia,
tremors.
√ Neuroleptic malignant syndrome → high fever, sweating, tachycardia,
agitation, confusion, muscle rigidity, neck stiffness.
◙ Haloperidol → Sexual Dysfunction + Gynecomastia.
◙ Fluoxetine (SSRI) → Anorgasmia (delayed ejaculation). Other: hyponatremia
So, in a man who has erection but no or delayed ejaculation → Fluoxetine
202
Warfarin
Side effects
In any patient on to urgently report is
Warfarin, the most important symptom that he needs
→ HEADACHE
(This is because people on warfarin are liable to subdural hematoma
which presents with headache and other features)
203
Bisphosphonates and side effects
◙ In any patient on needs to be urgently reported is
Bisphosphonates, the most important symptom that
→ Severe, sudden Heartburn ▐ or Chest pain (either is correct)
204
A 29-year-old female presents with sore throat. She has poorly controlled
asthma.
Her medications for asthma include beclomethasone, montelukast,
salbutamol, salmeterol and Aminophylline.
She developed white patch on
the pharynx that dislodges easily. What is the cause of her sore throat?
◙ Among the common side effects of Inhaled Corticosteroids (Beclomethasone)
→ Oral/ Pharyngeal Candidiasis, Sore Throat, Dry mouth and throat.
◙ Among the common side effects of SABA (Salbutamol)
→ Tachycardia, Palpitations, Tremors, Shaky hands.
205
◘ Excess intake of SSRIs (eg, Fluoxetine, Sertraline, Citalopram)
→ fever, sweating, tachycardia, agitation, confusion, muscle rigidity/
twitching, neck stiffness, others
→ Serotonin Syndrome.
206
◘ Excess intake of Dopamine antagonist (eg, Metoclopramide/ Haloperidol),
or potent antipsychotics (eg, Clozapine).
→ fever, sweating, tachycardia, agitation, confusion, muscle rigidity/
twitching, neck stiffness, others.
→ Neuroleptic Malignant Syndrome.
207
207
A lung cancer patient with shoulder pain has been shifted from oral
morphine to fentanyl patch due to nausea caused by oral morphine.
He was
also given metoclopramide for nausea and vomiting. A few hours later, his
neck has become weak and stiff. What is the reason for these new
symptoms?
→ Side Effect of Metoclopramide treatment.
208
man with bipolar disorder for 10 years and knee pain for which he takes
ibuprofen develops tremors, vomiting and confusion while travelling a long
distance.
The most appropriate test to be done → Serum Lithium concentration.
Note, Diuretics and NSAIDs (e.g., Ibuprofen) increase renal reabsorption of
lithium
and hence, the serum lithium increases and may lead to toxicity.
209
A renal cancer patient who was on morphine with good pain control started
vomiting, and was placed on metoclopramide.
He developed neck stiffness
and rigidity. What is responsible for the symptoms
◘ Excess intake of SSRIs (eg, Fluoxetine, Sertraline, Citalopram)
→ fever, sweating, tachycardia, agitation, confusion, muscle rigidity/
twitching, neck stiffness, others
→ Serotonin Syndrome.
◘ Excess intake of Dopamine antagonist (e.g. Metoclopramide/ Haloperidol),
or potent antipsychotics (e.g. Clozapine).
→ fever, sweating, tachycardia, agitation, confusion, muscle rigidity/
twitching, neck stiffness, others.
→ Neuroleptic Malignant Syndrome
210
man with chronic liver impairment being started on a new drug that is
lipid soluble,
strongly binds to albumin and undergoes hepatic first pass
metabolism. What adjustments are to be made
Since his liver is not functioning well, this would result in higher
concentrations of the new medication being flowed into the systemic
circulation. (the liver will not filter it well = ↓ hepatic first pass effect).
So, to reduce a possible drug toxicity, the dose needs to be reduced
and given on wider intervals
211
A Transgender woman (male to female) on spironolactone, oestrogen, Co-
codamol, lansoprazole, ramipril presents with hair loss and oesophageal
reflux.
Background history of hypertension and osteoarthritis. Most like
cause of hair loss
√ Oestrogen can cause hair loss.
√ Spironolactone is an anti-androgen (i.e. reduce the hair loss theoreticall
212
patient in depression. Switched from fluoxetine to citalopram.
Presents
with painful right red eye with visual blurring.
Citalopram (a SSRI) is associated with acute angle-closure glaucoma as one
of the side-effects.
Urgent referral to ophthalmology
213
Young lady with acne/ pigmentation on her face relating to menstrual
cycles.
She was prescribed Benzoyl Peroxide and (some other drug). These
drugs acts against which group of bacteria?
Adding topical benzoyl peroxide (BPO) to the antibiotics can reduce resistant
Propionibacterium acnes in patients with acne receiving antibiotic therapy.
214
A man who had cellulitis originating from ankle and spreading. Culture
revealed MRSA resistant staph aureus. What is the initial treatment?
√ MRSA (Methicillin-Resistant Staphylococcus Aureus)
√ Vancomycin continues to be the drug of choice for treating most MRSA
infections caused by multi-drug resistant strains.
√ Clindamycin, co-trimoxazole, fluoroquinolones or minocycline may be
useful when patients do not have life-threatening infections caused by
strains susceptible to these agents.
215
Patient with fever, cough, breathlessness. He is on certain medications
including simvastatin, Bisoprolol.
He is also Diabetic and hypertensive on
ramipril, simvastatin and metformin. Patient is to use erythromycin. What’s
the next thing to do?
When using macrolides (e.g. Clarithromycin, Erythromycin),
→ STOP SIMVASTATIN!
In other words,
Concomitant use of Clarithromycin + Simvastatin is Contraindicated!
Note, Clarithromycin + Atorvastatin (not Simvastatin) is OK
216
Burning Pain. Type 1 Diabetes Mellitus with retinopathy and nephropathy.
Which drug to give for his neuropathic pain? (No amitriptyline in options
In Diabetic Neuropathy:
Neuropathic pain can present in any form of the following:
(Burning), (Tingling), (Numbness), (Itching), (Paraesthesia), (Shooting/
Stabbing)
Example, a diabetic patient with ankle ulcer with agonising Burning Pain.
Rx? → Amitriptyline (1st line) or Gabapentin or Duloxetine or Pregabalin.
Away Goes D neuropathic Pain
(+) Good glycemic control
217
34-year-old woman presents with itchy rash. She is a taxi driver and
requests medication that will not affect her alertness.
She has an urticaria
like rash. What is the most appropriate medication
She requires NON-SEDATING anti-histamine such as Cetirizine, Loratadine.
Note, Chlorpheniramine is Sedating anti-histamine.
218
A 32-year-old man presents with erectile dysfunction of 2 months. He had
depression 3 months ago and was started on Sertraline.
He has no medical
history of note. What is the most likely reason for his symptoms?
SSRI-induced sexual dysfunction can occur in both men and women.
SSRIs examples → (Fluoxetine, Sertraline, Citalopram)
Setraline side effects
219
Pain ladder (Analgesia Ladder)
1) Simple analgesia → Paracetamol, NSAIDs, Aspirin.
2) Weak opiates → Codeine, Tramadol, Dihydrocodeine.
3) Strong opiates → Morphine, Fentanyl patches, Diamorphine, Oxycodone.
√ Remember, we should not go back on the pain ladder, we either go
forwards, ↑ dose, replace to a stronger option or add-on. (No Backward on
the ladder).
√ Fentanyl patches have a slow onset of action; therefore, they should be
avoided in a patient who is still in pain.
220
44 YO woman had rib fracture and is now due for discharge. She still
needs pain relievers at home.
Knowing that she has bipolar disorder and is
on lithium, what is the most appropriate pain killer for her among the
options?
◙ Lithium and (NSAIDs) e.g. ibuprofen interaction:
→ ↑ renal reabsorption of lithium i.e., ↓ renal clearance of lithium √.
→ ↑ Risk of lithium Toxicity.
Note, Diuretics and NSAIDs (e.g., Ibuprofen) and Aspirin increase renal
reabsorption of lithium and
hence, the serum lithium increases and may lead
to toxicity.
221
222
NSAIDs
√ Therefore, NSAIDs (e.g., Ibuprofen, Diclofenac, Naproxen) should not
be used in concurrence with lithium as they can increase the serum
concentration of lithium and thus lead to lithium toxicity.
√ Codeine is safe to be used with lithium.
√ Aspirin is not a typical pain killer for injuries.
223
Notes on: Co-careldopa (Sinemet ®)
√ Co-careldopa = Levodopa + Carbidopa combined together.
√ Used in the treatment of Parkinson’s disease.
√ Sudden cessation of Co-careldopa can result in Akinesia.
√ Akinesia = inability to move muscles voluntarily.
√ If a Parkinson patient on Co-careldopa (Sinemet ®) develops hallucination
→ Reduce the dose of Co-careldopa
224
Important Side Effects of TB Medications
Isoniazid (INH) Peripheral Neuropathy (Give Vit. B6)
Hepatitis
INH (3 letters)
→ SLE
225
Rifampicin
Red-orange urine and secretions
P45o induction
Hepatitis
226
Pyrazinamide
↑ Uric Acid (Hyperuricemia) → Gout
227
Ethambutol
Visual (Eye) Problems:
e.g. Red-green discrimination.
Retrobulbar neuritis, ↓ Visual acuity.
228
Streptomycin
Ototoxic → Deafness
229
A patient was diagnosed with TB and now presents with orange
urine and sweats and mildly elevated liver enzymes.
The likely cause → Rifampicin
230
Patients with diarrhea are at risk of dehydration (due to loss of
body fluid in the stool).
Therefore, it is important to consider
stopping any diuretic drugs being used to avoid dehydration
.
Example:
A patient with gastroenteritis presents with diarrhea of 3 days. He is on a
number of medications:
Citalopram, Warfarin, Indapamide, Allopurinol and
Corticosteroids.
Which drug needs to be currently ceased?
→ Indapamide
√ Indapamide is a thiazide-like diuretic.
√ Diuretics should be stopped if there is diarrhea because of the risk of
dehydration.
231
Diuretic
√ Other examples of diuretics:
• Loop Diuretics (e.g. Furosemide)
• Thiazide-like diuretics (e.g.
bendroflumethiazide, indapamide)
• Potassium-sparing diuretics (e.g. Spironolactone/ Eplerenone)
232
patient was diagnosed with TB and now presents with orange
urine and sweats and mildly elevated liver enzymes.
The likely cause → Rifampicin
233
Patients with diarrhea are at risk of dehydration (due to loss of
body fluid in the stool).
Therefore, it is important to consider
stopping any diuretic drugs being used to avoid dehydration.
patient with gastroenteritis presents with diarrhea of 3 days. He is on a
number of medications:
Citalopram, Warfarin, Indapamide, Allopurinol and
Corticosteroids.
Which drug needs to be currently ceased?
Indapamide
√ Indapamide is a thiazide-like diuretic.
√ Diuretics should be stopped if there is diarrhea because of the risk of
dehydration.
√ Other examples of diuretics:
• Loop Diuretics (e.g. Furosemide)
• Thiazide-like diuretics (e.g. bendroflumethiazide, indapamide)
• Potassium-sparing diuretics (e.g. Spironolactone/ Eplerenone)
234
An asthma patient is currently on different medications, one of
which is theophylline 120 mg.
The treating team want to increase
the dose of theophylline by 25%. What will be the new dose?
This is a question of a quick math.
25% means ¼
So, divide the current dose by 4 and add the result to the current dose.
120/4 = 30
30+120 = 150
Therefore, the new dose would be 150 mg.
“Such mathematic questions have been recently targeted in the PLAB 1 Test”.
235
A patient in status epilepticus is given IV lorazepam but is still having
fits. 20mg/kg Phenytoin is decided to be given at a rate of
50mg/minute.
The patient’s weight is 100 Kg. This means that the
patient should receive the total dose of phenytoin over how many
minutes?
This is another math question.
The dose of phenytoin to be given is 20mg/kg.
His weight is 100 Kg.
So, the total dose is 100 X 20 = 2000 mg
The rate is 50mg/min.
So, 2000/50 = 40 minutes.
The answer is 40 minutes.
236
237
238
patient in status epilepticus is given IV lorazepam but is still having
fits. 20mg/kg Phenytoin is decided to be given at a rate of
50mg/minute.
The patient’s weight is 100 Kg. This means that the
patient should receive the total dose of phenytoin over how many
minutes?
This is another math question.
The dose of phenytoin to be given is 20mg/kg.
His weight is 100 Kg.
So, the total dose is 100 X 20 = 2000 mg
The rate is 50mg/min.
So, 2000/50 = 40 minutes.
The answer is 40 minutes.
“The patient will receive 2000 mg of phenytoin over 40 minutes at a rate
of 50 mg/min”.
“Such mathematic questions have been recently targeted in the PLAB 1 Test”.
239
An opioid user presents with miosis, bradycardia, low respiratory rate
Give
→ Naloxone. “opioid overdose”.
240
An opioid user has been trying to stop for 2 weeks but still has
withdrawal symptoms
Give →
Methadone.
“for detoxification, relieve withdrawal symptoms”.
241
• An ex Opioid user has stopped using opioid and his urine shows no
trace of opioids.
He wants to stay away from opioid
Give → “
maintain abstinence”.
Naltrexone
242
Dealing with Constipation
Impacted stool → phosphate enema. “important”.
However, if young, healthy, no comorbidities, try Glycerol suppositories
first. “
important”.
• Hard stool → stool softeners.
243
244
Constipation
Mng
The order of interventions for constipations in general are as follow:
• High fibre (residue) diet + ↑ fluid intake, exercise (conservative)
• Senna (Stimulant Laxatives).
• Lactulose or Macrogol (Osmotic “Bulk-forming” Laxatives)
• Add a prokinetic agent (such as domperidone, metoclopramide,
erythromycin)
• Dantron.
• Seek specialist advice.
N.B. Senna is tried before lactulose in general.
However, in pregnancy, we use Ispaghula “1st lin
245
Pregnancy mng constipation
N.B. Senna is tried before lactulose in general.
However, in pregnancy, we use Ispaghula “1st line” or lactulose “2nd line” as
Senna might ↑ abdominal discomfort.
246
short, for constipation, after trying conservative management
(increase fluid intake and high-fibre diet and exercise), the first line
is as follows:
♦ In general, → Senna (stimulant laxative).
♦ In general, → Senna (stimulant laxative).
♦ In pregnancy: ILS
√ First line → Ispaghula husk (bulk-forming laxative).
√ Second line → Lactulose (osmotic laxative).
√ Third line → Senna (stimulant laxative).
247
Opioid-induced constipation (eg, constipation after taking codeine)
→ Glycerol suppositories.
• Glycerol suppositories have both stimulant + stool-softening actions
248
Constipation in Palliative Care Patients
◙ For most cases of chronic constipation in palliative patients
→ Macrogol (osmotic laxatives). (each sachet is dissolved in half a glass of
water)
249
◙ For opioid-induced constipation in palliative patients
• → Senna (could be given tablets or syrup based on the ability to swallow).
• Another option → Bisacodyl (per-rectal suppository).
√ Both senna and bisacodyl are (stimulant laxatives).
√ Senna is preferred in those who can swallow (either syrup or tablets)
because it is easier to use regularly.
√ Bisacodyl suppository has a faster onset of action but because it is a
suppository, it is less preferred.
√ Avoid senna and bisacodyl (stimulant laxatives) in bowel obstruction.
250
35 YO presents complaining of sudden onset of abdominal pain,
drowsiness, nausea but no vomiting, darker urine for 2 days
. He is on
sodium valproate for his epilepsy. There is no fever. What investigation is
most appropriate?
→ Liver function test.
◙ Sodium valproate + (abdominal pain, vomiting, anorexia, drowsiness,
jaundice)
→ suspect liver impairment or pancreatitis.
Before commencing sodium valproate, check:
→ Liver function test.
→ Full blood count.
For any risk of potential bleeding as sodium valproate
can cause blood disorders”.
Also “in women in child-bearing age”
“Sodium valproate is highly teratogenic”.- do pregnancy test
251
A 50 YO man has been diagnosed with hypertension and his GP wants to
start him on lisinopril (ACE inhibitor).
What investigation should be
requested prior to lisinopril regimen?
→ Renal function test and electrolytes (esp. serum potassium).
√ eGFR baseline needs to be measured before starting ACEIs. The dose of ACEI
may need to be adjusted if there is renal impairment.
(needs to be repeated 1-2 weeks after initiating ACEIs for fear of AKI, then
annually).
√ If after initiating ACEI, renal function tests deteriorate
→ consider: renal artery stenosis.
√ Also remember that ACEIs can cause hyperkalemia.
252
A 70 YO man with HF has been diagnosed with hypertension and his GP
wants to start him on lisinopril (ACE inhibitor).
His baseline renal function
tests are within normal. What investigation should be requested after
starting ACE inhibitor?
→ Renal function test in 2 weeks.
253
An elderly man has recently been treated for infective COPD exacerbation.
He now has hallucination and claims that he chats with the queen of
England. He insists that there are aliens invading his room.
This behavioural
change is sudden. What is the likely medication that caused this condition
and what is the likely diagnosis?
Likely Dx → Corticosteroid-induced psychosis.
The likely causative medication → to treat his COPD exacerbation”.
Prednisolone
254
Remember that Beta 2 agonists e.g., “low serum potassium”. Imp √
salbutamol, terbutaline can cause
Hypokalemia
255
A 66 YO woman has recently completed a 10-day use of co-amoxiclav for
cellulitis presents complaining of:
Fatigue, nausea, vomiting, dark urine and itching.
ALT is high: 150 (normal is up to 35).
ALP is 180 (normal is up to 60).
ALP, GGT and Bilirubin are elevated.
Abdominal U/S shows no evidence of biliary obstruction or gallstone.
She drinks 5 units of alcohol per week.
What is the most likely Dx?
[Alcoholic hepatitis / Hepatitis B / Cholestatic hepatitis / Choledocholithiasis]
√ Alcoholic hepatitis: her drinking Hx is not significant “only 5 units/ week”.
√ Hepatitis B: Her ALT is not extremely high. No points mentioned in the
question favouring hepatitis B.
√ Choledocholithiasis “gallstones in the bile duct”: U/S abdomen excludes this
option.
o Cholestatic hepatitis → Old age, Hx of a recent use of co-amoxiclav
(Augmentin) “drug-induced hepatotoxicity”.
Features: dark urine, itchiness “pruritis”, fatigue, nausea, vomiting,
abdominal pain.
Labs: ↑ ALT, ↑ ALP “alkaline phosphatase”, ↑ GGT, ↑ bilirubin.
256
Important Differentials of Liver Disease
o 1ry Biliary Cirrhosis → Middle-aged female, Pruritus, Jaundice,
↑ ALP, associated with Sjogren’s Syndrome.
Investigation: Anti-Mitochondrial Antibodies.
o 1ry Sclerosing Cholangitis → the same but the association is usually IBD
(mainly Ulcerative colitis).
Investigation: ERCP
o Autoimmune hepatitis → Early-middle aged female, abnormal ALT and
AST, Normal or mildly elevated ALP ±
2ry Amenorrhea ± another
autoimmune disease (e.g. hypothyroidism,
vitiligo,
rheumatoid arthritis,
celiac,
pernicious anemia)
257
Important Differentials of Liver Disease
1. Alcoholic Liver Disease → Hx of heavy alcohol consumption.
Signs of liver
disease/ cirrhosis: Ascites, Hematemesis, Jaundice,
Hepatomegaly, Spider
naevi.
Both AST and ALT are elevated; however, AST is more elevated
than ALT: ↑AST:ALT ratio (e.g. AST:150, ALT: 70).
Gamma Glutamyl
Transferase (GGT) is also increased.
2. o Cholestatic hepatitis → Old age,
Hx of a recent use of co-amoxiclav
(Augmentin) “drug-induced hepatotoxicity”.
Features: dark urine, itchiness “pruritis”, fatigue, nausea, vomiting,
abdominal pain.
Labs: ↑ ALT, ↑ ALP “alkaline phosphatase”, ↑ GGT, ↑ bilirubin.
258
A 60 YO man known case of hypertension, diabetes mellitus and a previous
TIA presents complaining of a 5 day of diffuse muscle pain and weakness in
his lower limbs. He is on: ramipril, bisoprolol, aspirin, metformin and
simvastatin.
His urine shows myoglobin. His kidney function tests are
deteriorated. His serum creatinine kinase (CK) is 3000 (Normal: 45-260).
√ The likely Dx → Rhabdomyolysis.
√ The likely causing medication that needs to be stopped → Simvastatin.
Although uncommon, one of the side effects of statins is Rhabdomyolysis.
259
Rhabdomyolysis
• As skeletal muscles are dying → they release (Myoglobulin, Potassium,
Creatine Kinase…
).
• Common Scenarios and Hints: (Important √)
√ A person was trapped for several hours under a heavy object.
√ A fall followed by a long period of lying on the floor.
√ An elderly with frequent falls presents with Acute kidney injury.
√ IV drug abuser was found on the floor not moving for a long period.
√ Long-distance run (e.g. Marathon runner) “Severe Exertion/ Severe
Dehydration”.
√ Severe Crush injury.
√ Exercise-induced rhabdomyolysis (e.g. in athletes)
± Hematuria (Reddish Brown or Tea-coloured urine) (False Positive as the
cause of redness is myoglobulin (which has heme), while RBCs are not found
in urine dipstick).
± Hypotension.
± AKI “Acute kidney injury” → (High urea and Creatinine).
± Very high CK (Creatine Kinase).
260
Rhabdomyolysis
√ Although uncommon, one of the side effects of statins is Rhabdomyolysis. √
• Myoglobulin is nephrotoxic and thus can lead to Acute Kidney Injury (AKI).
Therefore, rehydration with is an essential initial step. That’s why
Rhabdomyolysis is a medical emergency that you have to be aware of!
IV fluid •
ECG must be performed as the released potassium from the dying muscles
(hyperkalemia) can be dangerous.
If ECG changes suggesting hyperkalemia
(Tall tented T wave, Wide QRS) are found:
→ Protect the heart by giving before anything else
!
IV Calcium Chloride or IV Calcium Gluconate
◙ Important points on Rhabdomyolysis:
√ Main Complications of Rhabdomyolysis → AKI and Hyperkalemia.
√ Initial management → (to try to avoid acute kidney injury).
√ Initial Investigation for management → ECG
√ If Tall T wave, Wide QRS, the initial line → IV fluid give IV calcium chloride/
gluconate.
CPK level (Creatine Phosphokinase) “it indicates muscle
√ The best initial test that is specific for Rhabdomyolysis → Urine analysis →
Reddish-brown (Tea-coloured) → Falsely +ve hematuria.
√ To confirm → necrosis”.
√ Other lines of treatment include: Sodium Bicarbonate
▐ Dialysis (in severe cases)
261
In a recent exam, a man with asthma exacerbation had been advised to take
oral prednisolone for 5 days. What is the more likely side effect to develop?
→ Sleep disturbance.
“Oral thrush was among the options. However, sleep disturbance is more
common. Also, oral thrush is more common with inhaled steroids”.
We know that long-use of “inhaled” corticosteroids can cause → oral thrush.
• However, short-term use of “oral” corticosteroids can cause
→ Sleep disturbance, restlessness, indigestion.
262
One of the important side effects of → it SSRIs (e.g., Citalopram):
increases the risk of fall especially in the elderly
(As it can cause hyponatremia which leads to unstable gait).
263
One of the important side effects of → it SNRI (e.g., Duloxetine):
increases the risk of fall especially in the elderly
(As it can cause postural hypotension and impaired psychomotor function).
So, both SSRIs (eg, Citalopram) and SNRIs (eg, Duloxetine) can case frequent
falls especially in the elderly.
264
◙ If penicillin allergic and the patient is on methadone for opioid dependence
→ Doxycycline √
(do not use clarithromycin with methadone → risk of QT prolongation)
◙ For mild community acquired pneumonia:
→ Amoxicillin
◙ If penicillin-allergic
→ Clarithromycin “first” or Doxycycline.
265
Clarithromycin adverse effects
Some drug-interaction risks:
• Clarithromycin + Methadone → QT interval prolongation.
• Clarithromycin + Statin → rhabdomyolysis.
• Clarithromycin + salbutamol → hypokalemia.
• Metronidazole (Flagyl) + Alcohol → Disulfiram-like rection (headache,
nausea, stomach pain).
Thus, patients who drink alcohol and prescribed
Metronidazole should stop alcohol until after 48 hours of treatment end.
266
For local anaesthesia, why is adrenaline sometimes added with the
lidocaine
(What is the benefit of this combination of adrenaline +
lidocaine)?
→ To PROLONG the duration of the local anaesthesia.
Adrenaline → constricts blood vessels → delays the absorption of lidocaine.
267
A patient with DM type 1 is at a GP clinic for his regular insulin refill. The
patient shows the GP a picture of his empty insulin box.
He shows the GP his
CickSTAR pen. He tells the GP that he is using 86 units each evening. What
should be written in the prescription?
Units and International units should be written fully, do not use U or IU.
• Insulin prescription has to include the “Brand” name.
• If the patient is using it via reusable pen, not injections, this should be
included in the prescription. (As is shown here in the picture and in the stem).
Therefore, the right prescription would be as follows:
→ Insulin glargine (Lantus) 100 units/ml penfill 3 ml cartridges 86 units
subcutaneously each evening.
268
patient with DM type 1 is at a GP clinic for his regular insulin refill. The
patient shows the GP a picture of his empty insulin box.
He tells the GP that
he is using 78 units each night. What should be written in the prescription
Here, both brands Lantus and Solostar have to be included.
Also, this is to be injected in a “pre-filled pen” as is shown in the picture.
This has to be included.
→ Insulin glargine (Lantus) pre-filled SoloStar pen 78 units each night.
In the previous example, the patient has his “reusable” pen and needed the
box that contains solutions (penfill = cartridges).
Here, as is written on the
box, pre-filled pens (disposable). Also here, SoloStar “brand for disposable
insulin Lantus pens” should be included besides “Lantus”.
269
Smoking → ↑ the CYP1A2 enzyme. (a potent inducer).
Clozapine → atypical antipsychotic drug. It is metabolised by CYP1A2 enzyme.
Therefore:
If a smoker wants to stop smoking, the dose of clozapine has to be lowered.
(Because of the fear of clozapine toxicity)
Clarification:
When he stops smoking, the activity of CYP1A2 enzyme will be decreased
→ So, the metabolism of clozapine will also decrease (leaving a lot of it in
body) → Thus, after quitting smoking → reduce clozapine dose.
Another valid answer → measure the clozapine levels. (fear of toxicity).
270
40 YO man had a fight with his wife and then he drunk large quantity
of alcohol + a bottle of medication. This was 2 days ago.
Today, he has
developed severe epigastric pain (abdominal pain) & vomiting 6 hrs
ago.
His LFTs are abnormal.
What is the most likely medication being used in excess?
Aspirin, Paracetamol, amitriptyline, or Fluoxetine)?
The likely medication is → Paracetamol.
271
Paracetamol overdose:
√ After 12-36 hrs → nausea, vomiting, abdominal pain.
√ After 2-3 days →
hepatic necrosis; subcostal pain
and tenderness.
Acute kidney injury.
Hepatic encephalopathy.
272
Aspirin overdose:
√ Ringing in the ears (tinnitus).
√ Impaired hearing.
√ Rapid breathing (hyperventilation), (leading initially to resp. alkalosis but
later on metabolic acidosis develops).
√ Nausea and vomiting,
√ Dehydration,
√ Fever,
√ Double vision,
√ Feeling faint.
√ Abd. Pain.
273
Amitryptilin overdose
Dilated pupils – Dry mouth – Dry flushed skin – Drowsiness – Hypotension
–
Urine retention – Severe Sedation – Tachycardia – PR, QRS, QT prolongation –Severe Acidosis
274
• Fluoxetine overdose:
Tremors – agitation –
dilated pupils – drowsiness –
GI symptoms – ORS and
QT prolongation –
Torsades de pointes.
275
In the beginning, bear in mind that a concentration of:
1% → means: 10 mg/ml
And
0.5% → means: 5 mg/ ml
276
55 YO man weighs 100 kg presents for a procedure. He was given 30 ml of
0.5% lidocaine without epinephrine prior to the procedure.
If the maximum
allowed dose is 3 mg/kg, how much of 0.5% lidocaine can be given to him?
0.5% → 5 mg/ml (constant)
Max dose: 3mg/kg. He is 100 kg.
So, 3 X 100= 300 mg (max dose)
5 mg ----------→ 1 ml
300 mg ---------→ (X) ml
(X) = (300 X 1) ÷ 5 = 60 ml
He was already given 30.
, the remaining dose = 60 – 30 = 30 ml
277
A 42 YO man weighs 80 kg presents for a procedure. He was given 20 ml of 1%
lidocaine without epinephrine prior to the procedure.
If the maximum
allowed dose is 4 mg/kg, how much of 1% lidocaine can be given to him?
1% → 10mg/ml (constant)
Max dose: 4mg/kg. He is 80 kg.
So, 4 X 80= 320 mg (max dose)
10 mg ----------→ 1 ml
320 mg ---------→ (X) ml
(X) = (320 X 1) ÷ 10 = 32 ml
He was already given 20.
So, the remaining dose = 32 – 20 = 12 ml
278
Metronidazole (Flagyl) + Alcohol
→ Disulfiram-like rection (headache, nausea, stomach pain).
Thus, patients who drink alcohol and are prescribed Metronidazole should
→ Avoid alcohol during treatment and for at least 48 hours after stopping
treatment.
279
Which of the following medications can precipitate falls in patients with
postural hypotension and thus should be reduced or stopped?
(Ramipril – Metformin – Amitriptyline – Sitagliptin).
→ Ramipril.
◙ Important S/E of ACE inhibitors (e.g., lisinopril, enalapril, ramipril)
• Dry cough (Give ARBs e.g., Losartan instead -important-),
• Hyperkalemia.
• Precipitate recurrent falls in patients who have postural hypotension.
280
• So, remember these 3 side effects of clozapine:
√ Agranulocytosis: ↓↓WBCs (esp., neutrophils) + Fever, Chills, Muscle pain
→ Request full blood count (FBC).
√ Postural hypotension.
√ Weight gain. (So, if he is on clozapine and needs antidepressant, → Duloxetine)
281
Important Notes on Clozapine
• It is a psychiatric medication and is the first “atypical antipsychotic”.
• It is primarily used to treat people with schizophrenia.
• If a smoker wants to stop smoking, the dose of clozapine has to be lowered.
(Because of the fear of clozapine toxicity).
Clarification: Smoking increases the metabolism (breakdown) of clozapine.
When smoking is stopped, the metabolism slows down, leading to higher clozapine levels
in the body, which can cause toxicity.
So, clozapine dose must be checked and
decreased.
282
Important Notes on Clozapine
• One of the feared side effects of clozapine is agranulocytosis (severely low
WBCs especially neutrophils).
Agranulocytosis manifests as (Fever, Chills, Muscle
aches, Headache).
The next step is to request Full Blood Count (FBC).
Remember
that the antithyroid (carbimazole) can also cause agranulocytosis.
• Clozapine (atypical antipsychotic used mainly for schizophrenia) can cause
inhibitor -SNRI-).
weight gain (as a side effect).
So, if a patient is on clozapine and developed
depression and thus becomes in need to an antidepressant,
do not use
sertraline (SSRI), citalopram (SSRI), amitriptyline (tricyclic) or mirtazapine
(tetracyclic) as they all also cause weight gain.
We need an antidepressant that
causes weight loss such as Duloxetine
inhibitor -SNRI-).
283
One of the feared and important side effects of carbimazole (a drug used to
treat hyperthyroidism) is agranulocytosis (dangerously low WBCs especially
neutrophils
ie, neutropenia that can be asymptomatic or manifest with flu-
like symptoms).
A recent question asked about a side effect that should be instructed to a
hyperthyroidism patient who is going to start on carbimazole.
The answer was
(low neutrophils) (ie, agranulocytosis but in a different way).
284
Carbimazole and clozapine
→ Neutropenia
Low neutrophils) (ie, agranulocytosis but in a different way).
So, remember that both clozapine (atypical antipsychotic) and Carbimazole
(anti-hyperthyroidism medication) can cause agranulocytosis (ie, neutropenia)
and FBC should be requested if suspected.
Another question asks about a patient who is on carbimazole and developed
flu-like symptoms with headache, chills, fever and muscle aches.
What is the
most appropriate investigation?
(FBC) to look for neutropenia to diagnose agranulocytosis.
285
286
A 60 YO man has co-morbidities. He is on paracetamol, sertraline for
depression, and some medications for previous MI including ticagrelor,
bisoprolol, and atorvastatin,
He has recently developed muscle pain in arms,
shoulders and legs. What is the likely cause of his presentation?
Atorvastatin can cause → statin-associated myalgia
(Muscle pain in arms, shoulders, legs)
287
◙ The main neurotransmitter affected in Schizophrenia is
→ dopamine
288
Ramilpril
Zopiclone
Falls
Ramipril (ACE inhibitor) → Can cause postural hypotension and thus ↑ falls.
• Zopiclone → Insomnia treatment → can cause balance loss and thus ↑ falls.
289
Q] An elderly man feels dizzy when he stands and loses balance and falls. He
is on a number of medications: ramipril for hypertension, zopiclone
insomnia, cetirizine for allergy of hay fever, metformin for diabetes, and
lithium for bipolar disorder.
He has postural hypotension (his diastolic BP
while standing is > 10 mmHg lower than his diastolic BP while sitting).
Which
medication is the most likely reason for his recurrent falls?
→ ACE inhibitors (Ramipril). They can cause postural hypotension → thus falls.
Anti-hypertensive medications as ACE inhibitors and Calcium channel blockers
can cause postural hypotension → dizziness on standing → Falls.
Note: if there was no postural hypotension, we would suspect zopiclone
(Although rare, it can lead to falls by balance impairments).
290
What is the antiemetic of choice in patients with Parkinson’s disease?
→ Cyclizine. √ Others: domperidone.
Although ondansetron can be use in Parkinson; however; not ideal for elderly!
If vomiting persists in Parkinson’s disease → Levomepromazine. (2nd line)
291
Ci in Parkinson
Note that:
[May Cause Parkinson] ie,
Metoclopramide, Cinnarizine and Prochlorperazine
are contraindicated in Parkinson’s disease patients as they may worsen
symptoms.
Also, never use haloperidol in patients with Parkinson’s disease.
292
Remember that one important side effect of SSRIs [eg, Citalopram, Fluoxetine]
is →
Hyponatremia.
So, if a patient is on a number of medications and one of them is citalopram has
developed low serum sodium
(presented as confusion), think of Citalopram as
the causing medication.
293
SSRIs during Pregnancy
• SSRIs (eg, sertraline) have a small risk for congenital heart defect if used in
early pregnancy.
• Therefore, it is recommended -if mild to moderate- depression to
→ Stop sertraline (SSRIs) GRADUALLY.
→ “ie, • Never stop sertraline abruptly in pregnancy.
taper the dose of sertraline over 4 weeks and stop”
• However, in scenarios where the depression is very severe, we may continue
using sertraline (benefits outweigh risks).
294
A patient is on clozapine for schizophrenia has low moods. Since he
started clozapine, his weight has increased markedly.
What is the
most appropriate antidepressant for him?
→ Duloxetine. (It is SNRI, its side effects include weight loss)
• Clozapine (atypical antipsychotic used mainly for schizophrenia) can cause
weight gain (as a side effect). So, if a patient is on clozapine and developed
depression and
thus becomes in need to an antidepressant, do not use
sertraline (SSRI), citalopram (SSRI), amitriptyline (tricyclic) or mirtazapine
(tetracyclic) as they all also cause weight gain.
We need an antidepressant that
causes weight loss such as Duloxetine (a serotonin and noradrenaline reuptake
inhibitor -SNRI-)
.
• Pick sertraline if duloxetine was not in the options.
Even though both
sertraline and citalopram are SSRI and indicated as first-line anti-depressants,
citalopram has risk of QTc prolongation if co-prescribed with clozapine.
• Other important side effects of clozapine:
- Agranulocytosis (neutropenia) [FBC is needed]
- Postural hypotension.
- Weight gain
295
One of the recently added (2022) side effects of [Metformin] is
→ Vitamin B12 deficiency.
So, in a diabetic patient who develops symptoms of vitamin B12 deficiency such
as irritability, depression (low moods), fatigue and tiredness, weakness
→ Check serum vitamin B12 deficiency.
Rx → Correct vitamin B12 deficiency and continue on metformin.
296
Other side effects of Metformin
:
Weight loss – Vit B12 deficiency – Nausea, vomiting - Stomach pain – Gases
Remember that being vegan, gastrectomy are risk factors for vitamin B12 def.
297
A patient with type 2 DM is on metformin, dapagliflozin, gliclazide, atorvastatin.
His HbA1c is 42 (normal is <48). He has developed erythema and itchiness on his
penis (glans penis and prepuce). What medication should be stopped?
→ Dapagliflozin.
◙ Gliflozin eg, Dapagliflozin (SGLT-2 inhibitors) (for type 2 DM)
→ ↑ risk of genital infections (eg, balanoposthitis = inflammation of the glans
penis and prepuce → erythema, itching). → Stop or change medication
298
Important Notes on Gliflozins (SGLT-2 Inhibitors) “Asked Previously
• SGLT-2 inhibitors (Gliflozin) have increased risk for euglycemic DKA.
• SGLT-2 inhibitors (Gliflozin) have an important side effect to remember →
Genital infections eg, balanoposthitis (erythema and itchiness on the penis
glans and prepuce).
• In diabetic patients who have heart failure “HF” with reduced ejection
SGLT2 inhibitors such as Dapagliflozin, Empagliflozin
volume
Give → (When SGLT2 inhibitors are added to the medications of HF which are B-
blockers, ACE inhibitors, Aldosterone antagonist → they reduce cardiovascular
death).
So, in DM with heart failure, use metformin and flozin family
299
A 55 YO lady with osteoporosis and crohn’s disease is on bisphosphonate and
azathioprine. She has recently used oral prednisolone for the management of
acute flare-up of crohn’s disease. She has recently also used paracetamol and
ibuprofen for back pain. Her blood test today is as follows:
Hemoglobin 130 g/L.
WBCs 15 X 109/L (4-11).
Platelets 560 X 109/L (150-400).
What medication is responsible for her blood results?
→ Prednisolone.
• Of the side effects of prednisolone (corticosteroids) → thrombocytosis and
leucocytosis.
Glucocorticoids (eg, prednisolone, dexamethasone) → ↑ WBCs, ↑Platelets.
• This is why prednisolone can be used in the management of the idiopathic
thrombocytopenic purpura (as it elevates platelets)
300
If lithium toxicity developed
(eg, blurry vision, tinnitus = ringing ears,
dizziness,
lethargy,
muscle weakness, diarrhea,
vomiting
)
→ Stop lithium and repeat serum lithium level every 6-12 hours + Supportive
care (There is no antidote to lithium toxicity).
When toxicity resolves, lithium can be restarted at a lower dose (Never stop
lithium suddenly; it has to be over a period of 3 months to prevent relapse).
301
Ramsay Hunt Syndrome (Herpes Zoster Oticus) √
√ Reactivation of Varicella Zoster Virus (VZV) in the geniculate ganglion of the
facial nerve (7th CN) → Facial palsy (ipsilateral facial palsy, loss of taste).
√ Otalgia “ear pain” “First symptom”, Tinnitus, Vertigo,
Unilateral Hearing
loss,
Painful rash/ vesicles/
blisters around the ear or on the auditory canal
√ Rx → First → oral Aciclovir (antiviral) + Corticosteroids (eg, prednisolone)
√ If lasted for > 3 months, it is called (post-herpetic neuralgia).
If this occurs
Give → Amitriptyline or Pregabalin or gabapentin or duloxetine.
Important Note:
Prednisolone should be started within 2 weeks of symptoms.
If The rash and
pain persist for more than 2 weeks, it is better to add on a neuropathic agent
eg, amitriptyline, or gabapentin or pregabalin or duloxetine. (
They would be
more beneficial than prednisolone after 2 weeks of the onset of symptoms).
So:
Aciclovir → up to 2 weeks, add prednisolone →
> 2 weeks and still pain → one
of the following:
Amitriptyline or Pregabalin or gabapentin or duloxetine.
“Generally, amitriptyline is preferred over other neuropathic agents”
.
302
◙ Herpes Zoster Ophthalmicus. √
√ Reactivation of Varicella Zoster Virus (VZV) in the Ophthalmic branch of the
Trigeminal nerve (5th CN).
√ Conjunctivitis, Keratitis, Painful Vesicles around the eye …etc.
√ Rx → Oral Aciclovir (antiviral) + Corticosteroids (eg, prednisolone)
303
A 71-year-old man presents to the GP with intense pain and weakness of the
right side of his face for the past 4 days.
He has been taking oral aciclovir for
the past 4 days but there is still pain that makes him unable to sleep.
There
are blisters on his right ear canal. What is the most appropriate medication to
add on?
→ Prednisolone.
• This is most likely a case of Ramsay Hunt Syndrome (Herpes Zoster Oticus).
• Rx → Oral antiviral (eg, aciclovir) [+] Corticosteroids (eg, prednisolone).
√ If lasted for > 3 months, it is called (post-herpetic neuralgia). If this occurs
Give → Amitriptyline or Pregabalin or gabapentin or duloxetine.
Also, if the pain lasts > 2 weeks, it is more beneficial to give a neuropathic
agent (eg, amitriptyline) than prednisolone.
Here, it is 4 days only, so add prednisolone on.
304
56-year-old man presents to the GP with intense pain and weakness of the
right side of his face for the past 4 weeks.
He has been taking oral aciclovir for
the past 4 weeks but there is still pain that makes him unable to sleep.
Additional paracetamol and NSAIDs were not beneficial.
There are blisters on
his right ear canal. What is the most appropriate medication to add on
?
→ Amitriptyline or gabapentin or pregabalin or duloxetine (neuropathic agent).
• This is most likely a case of Ramsay Hunt Syndrome (Herpes Zoster Oticus).
• Rx → Oral antiviral (eg, aciclovir) [+] Corticosteroids (eg, prednisolone).
305
Ramsay hunt syndrome
Since the pain is persistent for > 2 weeks (4 weeks here) → a neuropathic
agent (eg, amitriptyline) is more beneficial than steroids.
√ Steroids are preferred to be given within the first 2 weeks of the infection onset.
Important Note:
Start with oral aciclovir. Prednisolone should be started within 2 weeks of
symptoms.
If The rash and pain persist for more than 2 weeks,
it is better to
add on a neuropathic agent eg, amitriptyline, or gabapentin or pregabalin or
duloxetine. (They would be more beneficial than prednisolone after 2 weeks
of the onset of symptoms).
So:
Aciclovir → up to 2 weeks, add prednisolone → > 2 weeks and still pain → one
of the following: Amitriptyline or Pregabalin or gabapentin or duloxetine.
“Generally, amitriptyline is preferred over other neuropathic agents”
.
306
Risperidone
Antipsychotic medications causes increased prolactin level
(eg, prolactin Leading to →
Galactorrhea (milk discharge from nipples).
307
Management of Pain in Sickle Cell Anemia Crisis (Chest Pain):
A bolus of strong opioids (usually morphine)
• If the pain persists after reassessment:
Another boils of morphine
is given.
308
Management of Pain in Sickle Cell Anemia Crisis (Chest Pain
Notes:
√ Ibuprofen (NSAIDs) can be also given.
√ Oxycodone can be considered if morphine is not tolerated (as an alternative
and not as an additional medication).
√ Pethidine should be avoided in sickle cell anemia (risk of seizures).
√ If repeated boluses are needed within 2 hours:
Consider → Patient controlled analgesia.
Remember that:
Start with morphine bolus
→ Reassess in 30 min, if still in pain → Repeat morphine bolus.
309
Painful Muscle Spasm → Give muscle relaxant eg, ◙
This might be asked in the exam: For example, a long Scenario of a patient
with a history of bone metastasis causing bone pain that is CONTROLLED with
morphine but there is still muscle spasm that is irritating or painful.
Baclofen
310
Baclofen
Rx → Baclofen (a muscle relaxant can be given as an adjuvant).
Baclofen.
Botulinum toxin botox).
◙ Another example: A child with cerebral palsy has muscle spasm and
increased muscle tone. What medications can help relieve this muscle
spasticity? → baclofen
Another useful medication to know →
(= • Botulinum toxin, or Botox, is a toxin (protein) that works as a muscle
relaxant and stops muscle spasms. It is injected directly into the muscle.
• Baclofen is a skeletal muscle relaxant that can be used in muscle spasms that
might occur in
multiple sclerosis,
cerebral palsy,
spinal cord injury or
after stroke
or as an adjuvant with radiotherapy in bone metastas
311
Metoclopramide is an antiemetic that blocks dopamine receptors and thus
may cause parkinsonism effect (eg,
Neck stiffness and ↑ muscle rigidity).
If the patient is already with a history of Parkinson’s disease (on co-
careldopa),
metoclopramide can worsen the muscle stiffness and rigidity.
If he is not having Parkinson’s disease, metoclopramide may also sometimes
cause neck stiffness and increased muscle rigidity.
Another important medication that can cause parkinsonism (eg, neck
stiffness, muscle rigidity, tremors)
is (aripiprazole which is an antipsychotic
used in schizophrenia management).
Rx Procyclidine of drug-induced parkinsonism → (Anticholinergic).
(Procyclidine is an anticholinergic:
It can ↓ the effects of the cholinergic
excess that resulted from dopamine deficiency caused by metoclopramide).
So, in this case, we give procyclidine, not baclofen or botox
312
SSRIs and Erectile Dysfunction
A 48-year-old man has been having difficulty in achieving erection for the past 2
months.
He has been sextually active with his wife for six months. He takes
sertraline for depression for 3 months. He is on enalapril (ACE inhibitor) for
hypertension.
He has a history of taking cannabis and being a heavy alcoholic
but he has been abstinent for a year.
His testicles size is normal and his current
blood pressure is 124/82 mmHg.
What is the most likely cause for his erectile
dysfunction?
• All SSRIs can cause erectile dysfunction.
The most common SSRI to cause
erectile dysfunction and vaginal dryness → Paroxetine.
• SSRIs examples → (Fluoxetine, Sertraline, Citalopram).
• Although the other given options “may” also cause erectile dysfunction (HTN,
depression, ACE inhibitors, alcohol and recreational drugs),
the most obvious
and the more common cause of erectile dysfunction among the given options is
SSRIs (antidepressants).
313
314
SSRIs and Hyponatremia → Falls, Instable Gait, Confusion
• One important side effect of SSRIs (eg, sertraline, citalopram, fluoxetine) is
hyponatremia.
• If hyponatremia is chronic or if left untreated, it can lead to → instable gait,
recurrent falls, confusion, and even seizures and coma.
315
Important Medications that Can Cause Dry Non-Productive Cough
√ ACE inhibitors (eg, Ramipril, Lisinopril, Enalapril, Captopril).
√ Methotrexate.
Important Questions:
◙ If a patient is on ACEi for HTN develops a dry cough, what to do?
→ Change to Angiotensin receptor blockers (ARBs) eg, Losartan, Candesartan.
◙ Why Can Dry Non-Productive Cough Develop with Methotrexate?
√ Prolonged intake of methotrexate (such as in patients with Rheumatoid
Arthritis) can rarely lead to a severe condition → Pulmonary Fibrosis/
Pulmonary Toxicity/ Pneumonitis.
√ Pulmonary Fibrosis/ Pneumonitis → Dry cough, breathlessness, wheezes,
fever. Diffuse bilateral interstitial infiltrates on Chest X-ray may be seen.
◙ If he is on Methotrexate and develops dry cough, breathlessness,
and or wheezes. What to Do Next?
→ Discontinue methotrexate.
→ Refer the patient to the specialist who prescribed methotrexate to look for
alternative management (eg, if he was taking methotrexate for rheumatoid
arthritis, refer for rheumatology). He also would need PF management.
Other Side Effects of Methotrexate (MTX):
• Pulmonary toxicity (Cough, dyspnea, fever) → Stop if suspected pneumonitis.
316
Other Side Effects of Methotrexate (MTX):
• Pulmonary toxicity (Cough, dyspnea, fever) → Stop if suspected pneumonitis.
Bone marrow suppression → Stop MTX if significant ↓ in WBCs/Platelets.
• Liver and GI → Stop MTX if abnormal liver enzymes, stomatitis, diarrhea.
Methotrexate (MTX) is an anti-metabolite most commonly used in
chemotherapy to treat cancer, and as an immunosuppressant in auto-immune
diseases (eg, in rheumatoid arthritis).
317
A 77-year-old man with a background history of multiple myeloma is in hospital.
He is on 10 mg of oral morphine every 4 hours to manage his pain.
He is due for
discharge. What should be the dose of his slow-release morphine sulphate at
home?
He is currently on 10 mg every 4 hours in hospital
→ This means (24 hrs / 4 hrs = 6 times).
→ 6 times of 10 mg → 6 X 10 = 60 mg morphine per day (per 24 hours).
→ So, his daily dose of morphine in hospital is 60 mg (per 24 hours).
Divide it by 2 to be given twice a day at home
→ 60 mg / 2
= 30 mg twice a day of slow-release morphine sulphate.
So, the answer is → 30 mg twice a day.
318
First Lines for Ascites Management (eg, liver cirrhosis, cancer)
Spironolactone • Restrict sodium.
• Give diuretics → (the ideal choice of diuretics).
Spironolactone is an aldosterone antagonist. It is a potassium-sparing diuretic.
This means it increases sodium excretion but keeps (preserves) potassium.
319
Osteoarthritis Management in Short
• First line → Paracetamol ± Topical NSAIDs.
• Second line (if failed) → Add Oral NSAIDs or COX-2 inhibitor (give PPI as
well).
• If still in pain or NSAIDs are contraindicated → Weak Opioids e.g., Codeine.
(Codeine is preferred over tramadol for chronic pain).
• If still in pain → Stop weak Opioids and add a strong one e.g., morphine,
oxycodone, fentanyl.
320
54-year-old man presents to the clinic with fatigue and occasional palpitations.
His laboratory investigations show low serum sodium and high serum calcium.
He has been on indapamide for the past 3 years for hypertension.
He is also on
vitamin D supplements for vitamin D deficiency. What is the most likely cause
for his hyponatremia and hypercalcemia?
√ Thiazide diuretics (eg, indapamide) → can cause hyponatremia. They can also
reduce the renal excretion of calcium, leading to hypercalcemia.
⬆️Ans
√ Addison’s → hyponatremia and hyperkalemia (not hypercalcemia).
√ Cushing’s → hypernatremia and hypokalemia.
√ Vitamin D deficiency → Hypocalcemia (not hypercalcemia).
√ Vitamin D toxicity → Hypercalcemia (but nothing to do with hyponatremia).
321
322
Management of Constipation
◙◙ Impacted stool → Phosphate Enema.
However, if young, healthy, no comorbidities, try Glycerol suppositories
first. “important”.
◙◙ Hard stool but not impacted → Stool softeners.
◙◙ Constipation with soft stools
→ High fibre diet → Senna = (stimulant laxatives) (1st line),
→ Lactulose or Macrogol (ie, osmotic laxatives) (2nd line) in general
323
324
Pregnancy constipation ils
◙◙ Pregnancy with constipation →
√ First line → Ispaghula husk (bulk-forming laxative).
√ Second line → Lactulose (osmotic laxative).
√ Third line → Senna (stimulant laxative).
Ie, lactulose is preferred over senna in pregnant women.
325
◙◙ Constipation in Palliative Care Patients
◙◙ Constipation in Palliative Care Patients
◘ For most cases of chronic constipation in palliative patients
→ Macrogol (osmotic laxatives). (each sachet is dissolved in half a glass of
water).
◘ For opioid-induced constipation
• → Senna (could be given tablets or syrup based on the ability to swallow).
• Another option → Bisacodyl (per-rectal suppository).
√ Both senna and bisacodyl are (stimulant laxatives).
√ Senna is preferred in those who can swallow (either syrup or tablets)
because it is easier to use regularly.
√ Bisacodyl suppository has a faster onset of action but because it is a
suppository, it is less preferred.
√ Avoid senna and bisacodyl (stimulant laxatives) in bowel obstruction.
326
Important Possible Side Effects of Salbutamol to Remember
hypokalemia → Transient (low serum potassium).
Others → Tachycardia/ Palpitations/ Muscle twitching, tremors/ Shaky hands.
327
328
Important Side Effects -Recently Asked-
◙ Oxybutynin (anticholinergic) can cause dry eye and dry mouth.
◙ Spironolactone (aldosterone antagonist) can cause breast enlargement
(gynecomastia).
◙ Citalopram, Fluoxetine (SSRIs) can cause Hyponatremia (SIADH) → confusion,
lethargy.
329
A 37-year-old man with scabies need to be give oral ivermectin 200 microgram
per kilogram. His weight is 70 kg. What is the total dose to be given in mg?
1000 microgram (mcg) = 1 milligram (mg).
200 X 70 = 14000 microgram
14000/1000 = 14 milligram (14 mg).
330
Drug-Induced Parkinsonism
Scenario:
• A 65-year-old woman experiences increasing hand tremors and bradykinesia
after being prescribed risperidone for schizophrenia.
• Examination reveals significant motor symptoms.
• Which part of the brain is most likely being affected to cause these motor
symptoms
• Risperidone is an antipsychotic that can cause extrapyramidal symptoms
such as bradykinesia and tremors.
• These symptoms are characteristic of drug-induced parkinsonism.
• The striatum is primarily affected because it is the main region where
dopamine from the substantia nigra acts.
• Risperidone blocks dopamine receptors in the striatum, disrupting motor
control and leading to the observed symptoms.
331
Why Striatum; not Substantia Nigra?
• The substantia nigra produces dopamine, but the striatum is the primary
site where dopamine acts to regulate movement.
The blockade of dopamine receptors by risperidone in the striatum directly
causes the motor symptoms, making the striatum the correct answer.
332
Other Drugs Causing Drug-Induced Parkinsonism:
Risperidone -
Haloperidol -
Metoclopramide -
Prochlorperazine.
Do These Drugs Have the Same Effect on the Striatum?
Yes, Haloperidol, Metoclopramide, and Prochlorperazine all block dopamine
receptors in the striatum.
If the patient has Parkinson's disease, not drug-induced
parkinsonism (e.g., due to risperidone, like in this scenario), which part
of the brain is most likely being affected to cause these motor
symptoms?
Would it still be striatum or substantia nigra?
substantia nigra.
In Parkinson's disease, the primary pathology is the degeneration of
dopamine-producing neurons in the
The loss of these neurons reduces dopamine input to the striatum, leading to
the characteristic motor symptoms.
Therefore, in Parkinson's disease, the substantia nigra is the most likely part
of the brain being affected to cause these motor symptoms.
So: Parkinson’s → Substantia nigra ▐ drug-induced parkinsonism → Striatum.
333
Important Side Effects of Risperidone to Remember:
• Extrapyramidal symptoms (eg, tremors, bradykinesia),
Ie, drug-induced parkinsonism.
• Weight gain. • Sedation.
• Elevated prolactin levels, which can cause galactorrhea (milk discharge from
nipples).
334
A 78-year-old woman presents to the GP surgery after experiencing two falls
over the past month.
She reports feeling unsteady on her feet, especially when
getting out of bed at night. She denies any loss of consciousness or visual
disturbances but mentions feeling light-headed on occasion.
Her medical history
includes hypertension, for which she takes ramipril and amlodipine, type 2
diabetes managed with metformin and sitagliptin, and chronic insomnia, for
which she has been prescribed zopiclone.
Her blood pressure is 135/80 mmHg
when measured sitting, but when she stands,
it drops to 125/75 mmHg. She
denies any recent changes to her medications, and her full blood count and
electrolytes are within normal limits. Her ECG is unremarkable. Which of the
following is the most likely cause of her falls?
The most likely cause of the patient's falls is zopiclone (Option E).
Zopiclone is a
sedative-hypnotic medication used to treat insomnia, and it is known to cause
drowsiness, impaired coordination, and dizziness, particularly in elderly
patients.
These effects increase the risk of falls, especially at night when patients
get out of bed. In this case, the woman reports feeling unsteady at night, which
is consistent with the sedative effects of zopiclone.
• Ramipril (Option D) can cause orthostatic hypotension, but in this case, the
patient's blood pressure drop on standing is minimal and unlikely to be the
primary cause of her falls.
• Amlodipine (Option A), sitagliptin (Option B), and metformin (Option C) are
not commonly associated with an increased risk of falls due to dizziness or
drowsiness.
335
Key Points:
• Zopiclone can cause drowsiness and impaired coordination, increasing the
risk of falls, particularly in elderly patients.
• Falls typically occur at night when getting out of bed, as seen in this scenario.
• While ramipril can cause orthostatic hypotension, the patient's blood
pressure change on standing is minimal, making zopiclone the more likely
cause.
When will ramipril be the valid answer in this scenario?
Ramipril would be the valid answer if the patient’s blood pressure drop on
standing (orthostatic hypotension) was more significant.
In scenarios where the
patient experiences a larger drop in blood pressure when transitioning from
sitting to standing (e.g., a drop greater than 20 mmHg in systolic pressure or 10
mmHg in diastolic pressure), ramipril would likely be the cause of the falls due
to its known side effect of postural (orthostatic) hypotension.
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Quick Revision Key Notes on Pharmacology:
• Zopiclone can cause drowsiness, dizziness, and impaired coordination,
increasing the risk of falls, especially in elderly patients at night when getting
out of bed.
- Pick Zopiclone if falls occur at night or the patient feels unsteady when getting
up from bed, without significant blood pressure drops.
• Ramipril and other ACE inhibitors can cause postural hypotension (a drop in
blood pressure when standing), leading to dizziness and falls in elderly
patients.
- Pick Ramipril if there is a significant systolic blood pressure (SBP) drop of more
than 20 mmHg or diastolic blood pressure (DBP) drop of more than 10 mmHg
upon standing, indicating orthostatic/ postural hypotension.
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Quick Revision Key Notes on Pharmacology:
Furosemide (a loop diuretic) often causes both low sodium (hyponatraemia)
and low potassium (hypokalaemia), resulting in muscle weakness, cramps,
and fatigue.
- While sertraline can also cause hyponatraemia, it does not cause
hypokalaemia. If a patient has both hypokalaemia and hyponatraemia and is on both sertraline and furosemide, pick furosemide as the likely causative
medication.
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Quick Revision Key Notes on Pharmacology:
• Sertraline can cause hyponatraemia due to SIADH, leading to confusion,
dizziness, and lethargy.
- Example: A patient on sertraline develops confusion, dizziness, and lethargy
→ Consider hyponatraemia due to SIADH. SIADH is induced by sertraline -SSRI-
.
• Doxycycline should be taken after meals to avoid oesophageal irritation and
heartburn, which can occur if taken on an empty stomach.
• Statins should be withheld ie, stopped temporarily when patients are
prescribed Clarithromycin or Erythromycin to avoid increased statin toxicity,
including the risk of rhabdomyolysis. (Statins should be temporarily stopped
until the antibiotic course is completed).
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Bubble sign
◙ No gastric Bubbles → Oesophageal Atresia.
◙ Single Bubble → Gastric/ Pyloric Atresia.
◙ Double Bubbles (Double bubble sign: Oesophagus + Stomach) →
Duodenal Atresia.
◙ Triple bubble sign → Jejunal Atresia
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A pregnant woman attends for anomaly scan at 31-week gestation. She has
polyhydramnios. U/S → No fetal gastric bubbles.
Oesophageal Atresia.
♠ Polyhydramnios + Absent fetal Gastric Bubbles → Oesophageal Atresia.
♠ Logically, if nothing can pass into the stomach because of the
oesophageal atresia, there won’t be bubbles in the stomach!
♠ Important post-natal (after delivery) sign of oesophageal atresia:
→ inability to pass a catheter into the stomach
(X-ray would show the catheter is coiled in the oesophagus).
REMEMBER:
Coiled NGT after Road Traffic Accident → Diaphragmatic Rupture.
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Tenesmus
Tenesmus → a continual or recurrent inclination to evacuate the bowels,
caused by disorder of the rectum or other illness.
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Rectal carcinoma risk factors
Some RFs of Rectal Carcinoma:
♠ FHx ▐ ♠ Smoking ▐ ♠ Polyposis Syndromes ▐ ♠ Low fibre diet ▐ ♠ IBD
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Fibroadenoma
Firm, painless, mobile mass in a young woman’s breast → Fibroadenoma.
Investigation → Ultrasound
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Infection
► Post-Operative Infection.
It does not matter what the type of the surgery is. Generally, Post-op
infection is the most common complication seen, including local (wound)
infection, lung infection (Hospital-acquired pneumonia) and so on.
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After a hemi-arthroplasty:
♠ Post-operative infection is the commonest complication.
♠ Fat necrosis is very rare.
♠ DVT and Pulmonary embolism: can occur but not as common as infection.
This is because nowadays, early post-op mobilisation + Heparin/ Enoxaparin
are mandatory.
♠ Avascular necrosis cannot occur as the fractured head of the femur has
been already replaced.
Hemi-arthroplasty = a surgical procedure that involves replacing half of the
hip joint. Hemi means “half” and arthroplasty refers to “joint replacement.”
Replacing the entire hip joint is called total hip replacement (THR). A
hemiarthroplasty is generally used to treat a fractured hip.
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A 60 YO ♀ presents to the ED complaining of passing large amount of bright
red blood + Left lower abdominal pain for 2 days that is worse after eating +
Nausea but with no vomiting. The patient’s main diet is canned meat. There is
localised left lower abdominal tenderness without rigidity or rebound
tenderness.
On examining the rectum, blood is found on the examiner’s
glove.
Vital signs: (BP: 85/55), (HR: 105), (Temperature: 38°C), (RR: 19).
◙ The likely diagnosis → Bleeding diverticulitis.
◙ The most appropriate step → Urgent admission to the surgical ward.
◙ The most appropriate “INITIAL” step → IV fluid (she is hypotensive).
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Diverticulosis
♠ Diverticulosis → Outpouches (outward herniations) of the colonic wall.
♠ Low fibre diet + (age > 50 Years) are common precipitating factors. Patients
tend to consume lots of canned food that is low in fibres.
♠ Diverticulosis mainly affects the sigmoid colon (Left Lower Abdomen).
♠ It is Mainly Asymptomatic.
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Important:
What is the most likely outcome of acute diverticulitis?
• The likely outcome of acute diverticulitis after treating with IV antibiotics,
IV fluids, observation and keeping the patient NPO
→ Complete resolution (recovery).
• Only 20% of acute diverticulitis cases develop complications such as fistula,
abscess, bowel obstruction, perforation and or peritonitis
♠ Sometimes, the stools can get impacted inside the diverticulae leading to
infection → Acute Diverticulitis → left iliac fossa pain and tenderness, Fever,
Constipation.
♠ In the case of acute diverticulitis → Admit patient and give IV antibiotics.
♠ So, the asymptomatic disease is called (Diverticulosis) or (Diverticular
disease). When infected, it is called→ Diverticulitis.
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→ Arrange Urgent Admission to the surgical ward,
→ Take FBC “Haemoglobin” to see if blood transfusion is required, CRP to
confirm the presence of infection (diverticulitis),
→ Colonoscopy to correct and stop the bleeding source or even surgery if
there is a diverticular rupture.
◙ Do not forget: in diverticulosis, profuse bleeding per rectum
→ urgent admission.
• Only 20% of acute diverticulitis cases develop complications such as fistula,
abscess, bowel obstruction, perforation and or peritonitis.
♠ Bleeding/ ruptured diverticula are also complications (rare).
♠ If bleeding occurs:
→ Stabilise the patient by IV fluids, IV antibiotics,
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Grades of Hemorrhoids
Bleeding only no prolapse
Prolapse with defecation, spontaneous reduction
Prolapse with defecation,manually reduced
Prolapse incarcerated, can’t be manually reduced
If haemorrhoids (Piles) are Asymptomatic (even if advanced grade)
→ No surgical treatment is required
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After abdominal surgery (e.g. Splenectomy), blood supply of the stomach
might be affected during the operation
→ the stomach will be in ileus (non-
functioning) → accumulation of air inside the stomach
→ Acute Gastric Dilatation.
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On the second day post-splenectomy, a patient develops epigastric fullness,
tenderness, nausea and Vomiting, and gradually increasing abdominal
distension
. He is hypotensive (BP: 75/45) and Tachycardic (135 bpm).
◙ The likely diagnosis → Acute Gastric Distension.
◙ The next step should be → Insertion of NGT (Nasogastric Tube).
♠ The NGT will “deflate the stomach” and thus the signs and symptoms
would rapidly improve.
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♠ Why is there hypotension?
Acute Gastric Dilatation.
When stomach massively dilates, it compresses the surrounding vessels,
sometimes the aorta as well → blood pressure drops.
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◙ Numbness and Tingling of the thumb, index and middle fingers
→ Think of Carpal Tunnel Syndrome
√ Pregnancy is an important RF for Carpal Tunnel Syndrome (due to fluid
retention).
√ Tinel Test is not always positive in Carpal Tunnel Syndrome “very low
sensitivity”.
◙ The Transverse Carpal Ligament compresses the MEDIAN nerve.
◙ Thus, the treatment would be → Cut the Transverse Carpal Ligament
to release the pressure on the median nerve.
♠ Note: Transverse Carpal Ligament is also called = Flexor Retinaculum =
Anterior Annular Ligament.
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Anal Fissure
♦ Extremely painful especially on defecation (The patient may refuse rectal
examination because of the intense pain)!
♦ There are blood streaks on the stools.
♦ The patient my remember an event when they felt a sharp intense pain
while defecating.
♦ The constipation and straining are the precipitating factors. However, the
presence of an anal fissure would also cause constipation as the patient
would be so afraid to pass stool as it is severely painful!
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♠ Haemorrhoids → Blood + Intermittent, bearable “tolerable” pain or
painless/ splashes of blood.
♠ Perianal Abscess → Throbbing pain, swelling, Usually No blood.
♠ Anal fissure → Intense pain (unbearable), streaks of blood
◙ A man presents with severe pain in anus especially on defecation,
blood streaks on the stools and Hx of constipation.
The likely Dx → Anal Fissure.
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Management of an acute anal fissure (< 6 weeks):
√ Dietary advice: high-fibre diet with high fluid intake.
√ Bulk-forming laxatives are first-line – if not tolerated then lactulose should
be tried.
√ Lubricants such as petroleum jelly may be tried before defecation.
√ Topical anaesthetics.
√ Analgesia.
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◙ Management of a chronic anal fissure (> 6 weeks):
√ The above techniques should be continued.
√ Topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal
fissure.
√ If topical GTN is not effective after 8 weeks, then secondary care referral
should be considered for surgery (sphincterotomy) or botulinum toxin.
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